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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610245
Report Date: 12/22/2021
Date Signed: 12/23/2021 08:50:05 AM

Document Has Been Signed on 12/23/2021 08:50 AM - 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
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: DATE:
12/22/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:32 AM
MET WITH:Victoria ParedesTIME COMPLETED:
12:32 PM
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At approximately 11:32 AM, Licensing Program Analyst (LPA) Nicholas Reed arrived to Peaceful Kingdom 2 for a Case Management visit. LPA met with Administrator and discussed the purpose of the visit.

Census was 3 residents.

LPA was screened for temperature and COVID symptoms at the front, Staff took LPA’s temperature and instructed LPA to sign Visitor Log and a COVID symptom sheet.

At approximately 11:42 AM, LPA and Administrator addressed the facility’s fire safety. LPA heard 3 fire alarms beeping throughout the facility. Licensee reported the beeping in a phone conversation on 12/21/21. Licensee replaced all batteries in fire alarms, yet beeping persists.

In a tour of the kitchen, Administrator showed LPA a fire extinguisher which was inspected in March 2021. LPA approved of the extinguisher and discussed Fire Safety policies with Administrator.

LPA conducted exit interview, issued technical assistance, and emailed report to Administrator.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
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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