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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610245
Report Date: 03/10/2022
Date Signed: 03/10/2022 04:08:54 PM

Document Has Been Signed on 03/10/2022 04:08 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:
03/10/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Jose HernandezTIME COMPLETED:
04:15 PM
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At approximately 10:56 AM on 03/10/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced prelicensing inspection to verify deficiencies have been corrected. LPA met with Licensee and disclosed the reason for the visit.

Census: 3 residents

Water temperature – On 03/08/2022, LPA measured water temperature to be below 105 degrees Fahrenheit. On 03/10/2022, LPA measured water temperature at 122.5 degrees Fahrenheit at approximately 11:15 AM. LPA returned at approximately 2:45 PM measured water temperature at 121 degrees Fahrenheit. LPA measured water temperature at approximately 3:45 PM to be 119.8 degrees Fahrenheit.

All deficiencies found during the 03/08/2022 prelicensing inspection have been corrected.

LPA conducted exit interview and issued a copy of the report.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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