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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610245
Report Date: 04/08/2024
Date Signed: 04/08/2024 03:07:37 PM


Document Has Been Signed on 04/08/2024 03:07 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
WOODLAND HILLS S.RO, 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: 5DATE:
04/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:TIME COMPLETED:
03:35 PM
NARRATIVE
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At 10:15 AM Licensing Program Analysts (LPAs), Huma Rahimi, and DeLaCerra, Leizl conducted an unannounced annual inspection at the facility mentioned above. LPA met with staff Edidha Menor, Administrator Jose Hernandez, arrived later and the physical tour was conducted with the Administrator and LPAs observed the following:

At 10:15 AM, upon entry LPAs observed a very strong odor of urine.

Kitchen: 10:58 AM LPAs toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. At 10:58 AM, LPAs also observed a hammer in the kitchen drawer accessible to residents. At 11:01 AM, LPAs observed roaches on the ceiling, in the food pantry, and in the kitchen cabinets. At 11:04 AM, knives and sharps observed to be unlocked in a kitchen drawer and accessible to residents in care. LPAs observed a working washer and dryer next to the kitchen and laundry detergents, cleaning agents and other toxins were locked under the kitchen sink in the kitchen. A fire extinguisher hung near the kitchen. It was last inspected on 12/09/2023.

Medications: At 11:05 AM LPA observed medications are centrally stored and locked in the kitchen cabinet.
Bedrooms: The facility has total of five (5) bedrooms of which one is designated for staff use only. The facility has an approved fire clearance for six (6) bedridden residents. All bedrooms are properly furnished. At 11:09 AM, LPAs observed that the bedding and linens were with visible yellow stains (urine) and the edges of the bed sheets were torn. Facility has awake staff.

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
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 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PEACEFUL KINGDOM HOME CARE 2
FACILITY NUMBER: 197610245
VISIT DATE: 04/08/2024
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Bathrooms: LPAs observed two (2) bathrooms, and both appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPAs observed appropriate grab bar and resident's bathroom had non-skid mat. At 11:14 AM, hot water temperature measured at 113.4°F.

Common Areas: The facility maintains a comfortable temperature at 71°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. The garage is currently being used for storage and has an extra fridge for extra food.
Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 11:25 AM they were tested and observed to be operational. Carbon monoxide was located in the hallway and was also tested and observed to be operational.

Outside areas: PAs toured the outside area of the facility. LPAs observed that due to the rain the covered patio/office collapsed. LPAs were informed that the staff files were stored in the patio/office and cannot be accessed. LPAs were unable to obtain staff files for review. The facility does not have a swimming pool or any bodies of water.



At 1:00 PM, LPAs were unable to review residents records due to infestation of roaches to the files. LPAs will make a subsequent visit to review residents and staff records.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

Deficiencies cited during today’s visit. Appeal rights explained.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 04/08/2024 03:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: PEACEFUL KINGDOM HOME CARE 2
FACILITY NUMBER: 197610245

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)

Maintenance and Operation: a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based LPAs observation licensee did not comply with the section sited above by having cockroaches at the facility (kitchen, living room, resident's files), moreover licensee did not comply with section cited abot by not ensuring the entire facility was clean and free of odor. which poses a potential health and safety risk to residents in care.
POC Due Date: 04/15/2024
Plan of Correction
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Licensee/ Administrator agreed to provide proof of treatment for cockroaches and plan to prevent the pests from spreading in the facility.Administrator will also provide a deep cleaning service invoice in order to remove the strong odor of the facility. The proof shall be submitted to LPA by POC date
Type B
Section Cited
CCR
87211(a)(1)A,B,&D

Requirements: (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)...
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2024
Plan of Correction
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Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Copy of an incident shall be submitted to LPA by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 04/08/2024 03:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: PEACEFUL KINGDOM HOME CARE 2
FACILITY NUMBER: 197610245

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above knives and hammer stored in an unlocked area in the kitchen accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2024
Plan of Correction
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Administrator immediately removed and locked away the sharps. Administrator also agreed to provide training to their staff and provide LPA with a proof by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 04/08/2024 03:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: PEACEFUL KINGDOM HOME CARE 2
FACILITY NUMBER: 197610245

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(C)
Personal Accommodations and Services. The licensee shall assure provision of clean blankets, bedspreads, top and bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. All items shall be in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the resident's beds sheets were torn and visible yellow stains which poses a personal rights risk to residents in care.
POC Due Date: 04/15/2024
Plan of Correction
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Administrator will ensure that all of the beds are in good repair and have clean sheets. Proof of photos shall be submitted to CCL by POC due date.
Type B
Section Cited
CCR
87405(d)(1,2)
Administrator Qualifications - 87405 (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator... (1) Knowledge of the requirements...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews, the licensee failed to ensure that the administrator had knowledge of licensing rules and regulations which poses an immediate health and safety risk to the residents in care.
POC Due Date: 04/15/2024
Plan of Correction
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Licensee agrees to follow proper guidelines for Administrator Qualifications. LPA discussed with the Administrators’ section 87405. Licensee agrees to submit a written letter to CCL indicating that they have read the regulations, have full understanding
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 04/08/2024 03:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: PEACEFUL KINGDOM HOME CARE 2
FACILITY NUMBER: 197610245

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Upon LPA's request Licensee/Administrator was unable to provide one (1) out of three (3). LPAs were informed that the administrator could not locate their file. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2024
Plan of Correction
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Administrator agreed to have a complete file in the facility for themselves by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6