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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603565
Report Date: 09/16/2022
Date Signed: 09/16/2022 11:26:47 AM


Document Has Been Signed on 09/16/2022 11:26 AM - 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 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:
09/16/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gregg & Dolgorkhan Knapp- ApplicantTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) V. Maldonado conducted an announced visit to the facility for the purpose of conducting a Pre-Licensing inspection. LPA Maldonado met with applicant Gregg & Dolgorkhan Knapp and explained the purpose for the visit. An application was submitted to CCLD on 03/11/22, for initial license for a Residential Care Facility for the Elderly to serve residents of ages 60 years and older. The requested capacity is for 6 non-ambulatory residents, and have an approved hospice waiver for 6.

The facility is home located in a residential area, which consists of 4 bedrooms, 2 bathrooms, a kitchen, dining room, living room, back patio with shade, and attached garage. All passageways, walkways, and ramps were observed to be free of obstruction, debris, and hazards. The living room has a fire place with a glass cover, making it inaccessible to residents in care. Resident records, personnel records, and medications will be centrally stored in locked cabinets in the living room. The first aid kit will also be stored in the cabinet with the files and medication. The resident bedrooms were observed to have the required furniture, linens, and have sufficient storage space and adequate lighting. Bathroom# 1 and bathroom# 2 were observed to have an operating toilet, wash basin, and shower and had the required grab bars. Soap and paper towels were observed available for handwashing. Both bathroom showers will accommodate the non-ambulatory residents. The water temperature was measured at 87.9*F and 85.6*F- which does not meet the Title 22 California Code of Regulations. Sufficient additional linens, bath towels, and personal hygiene supplies were observed in the hallway cabinet. LPA observed the flatware, cups, and utensils to be sufficient and in good repair for resident use. The sharps were stored and locked in a kitchen drawer next to the sink, and cleaning supplies and toxins were stored and locked in a cabinet underneath the kitchen sink- inaccessible to residents in care. The refrigerator, stove and microwave are operational and in good repair. The food supplies was observed to be sufficient. Fire extinguishers were observed in the hallway, the kitchen, and in the garage. All had recent inspections and were fully charged.

(Report continued on LIC 809-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022
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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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 2
FACILITY NUMBER: 198603565
VISIT DATE: 09/16/2022
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The smoke/carbon monoxide detectors were tested and observed to be inter-connected and fully operational. The facility has a fire door at the end of the hallway, leading to resident rooms, which automatically closes when the fire alarm turns on. Fire Clearance was approved on 07/15/22. The attached garage will remain locked and inaccessible to residents in care. In the garage are the washer and dryer, operational and in good repair. Laundry washing supplies are maintained on a rack above the washer and dryer, inaccessible.

During the pre-licensing inspection, certain items were observed which do not comply with applicable laws and regulations. The following items must be corrected:

- Non-Skid mats for the showers
- Tweezers for the first aid kit
- A first aid manual
- Adjust the water temperature in both bathrooms to meet the California Code of Regulations requirement
-A free telephone available for resident use

Applicants have been notified to contact LPA Maldonado once the corrections have been made. The physical plant was not cleared during today's inspection, due to the corrections needed.

Component III orientation has been waived by applicants today, due to them completing it in the past.

An exit interview was conducted with applicants and a copy of this report has been furnished. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
LIC809 (FAS) - (06/04)
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