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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603028
Report Date: 03/14/2023
Date Signed: 03/14/2023 03:45:56 PM

Document Has Been Signed on 03/14/2023 03:45 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
GREATER LA AC/SC, 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: 4DATE:
03/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:22 PM
MET WITH:Gregg Knapp, AdministratorTIME COMPLETED:
03:48 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and met with Staff,Gregg Knapp who allowed entry. The purpose for the visit was explained. The facility is licensed for 6 residents ages 60 and over. The fire clearance is approved for 6 non-ambulatory residents. 1 Bedroom is approved for (1) bedridden. There is a hospice waiver approved for 3 residents.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan posted by the entrance.

Due to time constraints, LPA will return to complete annual inspection at a later day.

Exit interview conducted with Administrator Gregg Knapp and copy of report provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2023
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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