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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610245
Report Date: 12/17/2021
Date Signed: 12/17/2021 02:03:08 PM

Document Has Been Signed on 12/17/2021 02:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:PEACEFUL KINGDOM HOME CARE 2FACILITY NUMBER:
197610245
ADMINISTRATOR:PAREDES, VICTORIAFACILITY TYPE:
740
ADDRESS:17734 BALTAR ST.TELEPHONE:
(818) 339-3867
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 5DATE:
12/17/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Starr Craver, Applicant
Jose Hernandez, Applicant
Maria Victoria Paredes, Administrator		TIME COMPLETED:
02:00 PM
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Component II completion: Successful

Facility Type: RCFE
Application Type: Change in Ownership
Capacity: 6
Census (if any clients in care): 5
COMP II Participants: Starr Craver, Applicant
Jose Hernandez, Applicant
Maria Victoria Paredes, Administrator
Interview Method: Telephone interview

On December 17, 2021 at 1:00 PM, Applicants and Administrator participated in COMP II. Identification of the Applicants and Administrator was verified through interview questions based on photo ID (CA Driver License) and other identifying personal information. During COMP II, Applicants and Administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB analyst confirmed Applicants and Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness

Exit interview conducted with Applicants and Administrator. Analyst will send report via PDF email and informed, Applicants and Administrator to sign and return back to CCL.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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