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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603028
Report Date: 04/25/2022
Date Signed: 04/25/2022 03:15:37 PM


Document Has Been Signed on 04/25/2022 03:15 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, 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:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Licensee/Administrator Gregg KnappTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with licensee, Gregg Knapp. Licensee assisted with the tour and record review. LPA used the infection control tool to evaluate the facility. The physical plant was inspected along with COVID-19 procedures, medications, food supply, and resident and staff records. The facility has an approved mitigation plan on file.

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 118.6 degrees which is within the required 105 - 120 degrees. The kitchen appliances are operating properly. There was a sufficient amount of perishable and non-perishable food. The common areas include the living room and dining room. The facility is clean and has the required furniture. The facility does not have any cameras inside or outside the home.

All 5 resident files were reviewed to confirm emergency contacts and health screenings are updated. LPA reviewed staff files for proof of fingerprint clearance and health screenings. Files were complete and included proof of COVID-19 vaccinations. Residents' medications were reviewed. Medications are documented properly and given as prescribed.

Facility documents resident, staff and visitor temperatures. Facility also requires visitors to sign-in which are part of the COVID-19 procedures.

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: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022
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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