<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603028
Report Date: 05/02/2024
Date Signed: 05/02/2024 02:46:45 PM


Document Has Been Signed on 05/02/2024 02:46 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: 3DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Gregg & Anna Knapp- LicenseesTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Licensees Gregg and Anna Knapp, and explained the purpose for the visit.

During today's visit, LPA Maldonado conducted a tour of the physical plant with Caregiver, observed the facility food supplies, reviewed (3) resident medications, (3) resident files, (3) staff files, and conducted interviews with (2) staff, and attempted interviews with (3) residents. The facility is a single-story home, operating as a Residential Care Facility for the Elderly. It is licensed to serve (6) older adults, ages 60 and over. There is a fire clearance approved for (6) non-ambulatory residents, of which (1) may be bedridden. It has an approved Dementia Care Plan and a Hospice Waiver approved for (3) residents. There is currently (1) resident receiving hospice services. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review. The facility has an active and current liability insurance policy on file.

LPA observed all resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. There are (2) full bathrooms in the home- both equipped with required grab bars and non-skid mats for the shower. The hot water was tested and measured between 117*F-118*F, which is in compliance. Food supplies was observed and was sufficient as required. Emergency food supplies and water were available. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. Smoke/Carbon Monoxide detectors were operational. Auditory devices were observed at all entrances/exits of the home and were operational. (3) resident files and (3) staff files were reviewed. Residents files were observed to be complete with all required documentation. (2) of (3) staff were missing proof of required annual training certification. Per Licensee, staff have not received required annual training this year yet. (3) resident medications were reviewed and were observed to be documented properly and given as prescribed.

Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on LIC9099-D.
An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024
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 2


Document Has Been Signed on 05/02/2024 02:46 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: PEACEFUL GARDENS
FACILITY NUMBER: 198603028

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in (2) of (3) staff without proof of required annual training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
1
2
3
4
Licensee will ensure (2) staff in question complete the required annual training and will provide proof of completed training to LPA via email, by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2