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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610245
Report Date: 01/05/2022
Date Signed: 01/05/2022 02:27:52 PM

Document Has Been Signed on 01/05/2022 02:27 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, 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: 2DATE:
01/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Oscar and Teresita UllegueTIME COMPLETED:
02:27 PM
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At approximately 1:55 PM on 01/05/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted a Case Management visit. LPA met with staff and disclosed the reason for the visit.

Census: 2

LPA was screened for COVID-19 symptoms at the front entry door. LPA documented temperature on forms provided.

LPA heard Dementia buzzer as the front door opened.

LPA conducted a physical plant tour at approximately 2:00 PM. LPA met with both residents.

At approximately 2:14 PM, LPA and staff tested 8 smoke detectors and 1 Carbon Monoxide detector.

8 out of 8 smoke detectors and the carbon monoxide detector worked when tested. LPA still heard the smoke detector in the living room beep once every 30 seconds. Staff noted they replaced all batteries recently, and Licensee plans to call electrician to fix the one malfunctioning smoke detector.

Exit interview conducted and report issued.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2022
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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