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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603565
Report Date: 08/02/2022
Date Signed: 08/02/2022 01:42:58 PM


Document Has Been Signed on 08/02/2022 01:42 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:PEACEFUL GARDENS 2FACILITY NUMBER:
198603565
ADMINISTRATOR:KNAPP, GREGG AFACILITY TYPE:
740
ADDRESS:209 E CAMDEN STTELEPHONE:
(909) 406-3711
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY:6CENSUS: 0DATE:
08/02/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Gregg Knapp, Administrator/LicenseeTIME COMPLETED:
01:30 PM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Initial
Capacity: 6
Census (if any clients in care): none
COMP II Participants: Gregg Knapp, Administrator/Licensee
Interview Method: Telephone interview

On August 2, 2022 at 1PM, Administrator/Licensee participated in COMP II. Identification of the Administrator/Licensee was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Administrator/Licensee confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB Analyst confirmed Administrator/Licensee’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Administrator/Licensee and informed to return sign copy to CAB by end of business today, 5PM. Report sent via email pdf.
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: 916-657-2469
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
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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