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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610245
Report Date: 03/08/2022
Date Signed: 03/08/2022 02:55:34 PM

Document Has Been Signed on 03/08/2022 02:55 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: 3DATE:
03/08/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Starr HernandezTIME COMPLETED:
03:00 PM
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At approximately 1:06 PM on 03/08/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced prelicensing inspection. LPA met with Licensee and disclosed the reason for the visit. LPA toured the facility inside and out.

Census: 3

This prelicensing inspection was conducted for a change of ownership with residents in care. The facility had an approved fire clearance for 6 bedridden residents. The facility had 5 bedrooms and 2 bathrooms. LPA observed functioning auditory alarms on all exits. LPA tested smoke detectors and carbon monoxide detector to be functional. A fire extinguisher hung near the kitchen. It was last inspected on 01/24/2022. All hazardous items and chemicals were stored and locked.

LPA was screened for temperature and symptoms of COVID-19. Staff prompted LPA to record information in a visitor log. The facility had signs relating to COVID-19 hung throughout.

All rooms, furniture, ceilings, and floors were clean, temperate, in good condition, and free from odors. LPA observed postings at the dining area for resident rights, resident councils, confidential complaints, and ombudsman contacts. LPA also observed a free house telephone at the front entrance.

Bedrooms: Bedroom #2 was occupied by a bedridden resident. Bedroom #5 contained 2 residents, and one resident used oxygen. The bedroom had a “No smoking – Oxygen in use” sign posted on the door. Bedroom #3 was a staff bedroom. The bedroom was unlocked and contained no hazardous items. Bedroom #1 and Bedroom #4 were vacant. All bedrooms contained lamps, nightstands, adequate storage, and beds with sufficient sheets, blankets, and pillows.

In the hallway, LPA observed two linen closets with adequate supplies of clean hand towels, bath towels, and bedsheets. The facility leaves the hallway light on at night to illuminate the path to the communal bathroom.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 2
FACILITY NUMBER: 197610245
VISIT DATE: 03/08/2022
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Bathrooms: The facility had 2 bathrooms. One was a communal bathroom at the end of the hallway between Bedroom #1 and Bedroom #2. Another bathroom was private to Bedroom #5. All bathrooms contained fully stocked liquid soap, paper towels, trash cans with lids, non-skid material on the shower floors, and handwashing instruction signs. Toilets did not have grab bars, but residents in care used commodes with grab bars. The facility also has extra assistive toileting devices for new residents.

Kitchen: LPA observed adequate supplies of perishable and non-perishable food. LPA also observed a weekly menu. All surfaces were sanitary and tidy. LPA saw a first aid kit with an approved manual, dressings, bandages, scissors, tweezers, and thermometer.

LPA observed water temperature in the communal bathroom to be 103.9 degrees Fahrenheit. LPA observed temperature in the refrigerator and freezer to be 30.1 degrees Fahrenheit and -16.1 degrees Fahrenheit, respectively.

Outdoor: LPA observed all exit paths to be free from obstructions and unlocked. Outdoor areas were well maintained.

LPA reviewed Component III with Licensee.

LPA issued report and conducted exit interview.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC809 (FAS) - (06/04)
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