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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603028
Report Date: 12/02/2021
Date Signed: 12/02/2021 02:47:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PEACEFUL GARDENSFACILITY NUMBER:
198603028
ADMINISTRATOR:KNAPP, GREGG AFACILITY TYPE:
740
ADDRESS:1033 E VIRGINIA AVETELEPHONE:
(909) 406-3711
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY:6CENSUS: 5DATE:
12/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Gregg Knapp, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with licensee, Gregg Knapp and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. Facility has submitted a mitigation plan and the plan has been approved.

All resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Both bathrooms were toured. Bathrooms have the required grabs bars and non-skid mats. The hot water was 108.4 degrees which is within the required 105 - 120 degrees. The kitchen was toured. All appliances were operating properly. There was a sufficient amount of perishable and non-perishable food. The common areas including the living room and dining room are clean and have the required furniture. The facility does not have any cameras inside or outside the home.

LPA reviewed all resident files for updated emergency contacts and health screenings. All resident files were complete and included proof of COVID-19 vaccinations. LPA reviewed staff files for proof of fingerprint clearance and health screenings. Files were complete and included proof of COVID-19 vaccinations. All residents' medications were reviewed. Medications are documented properly and given as prescribed. At the time of entry LPA was required to conduct a COVID-19 assessment and was required to sign-in which is part of the COVID-19 procedures facility must follow.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held. A copy of the report was provided to licensee.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
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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