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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603565
Report Date: 09/23/2022
Date Signed: 09/23/2022 03:57:47 PM


Document Has Been Signed on 09/23/2022 03:57 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 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:
09/23/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Gregg & Dolgorkhan Knapp- ApplicantsTIME COMPLETED:
04:00 PM
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Licensing Program Analyst's (LPA's) V. Maldonado and K. Ramirez conducted an announced subsequent visit to the facility for the purpose of conducting a Pre-Licensing inspection and to ensure the previous listed items were corrected. LPA's Maldonado and Ramirez met with applicants 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.

During today's visit, LPA's observed the following items to be corrected:
- Non-skid mats were observed in both resident showers.
- Tweezers were observed in the first aid kit
- A first aid manual was observed available and is stored with the first aid kit
- The water temperature in bathrooms#1 and #2 were tested and measured at 109.2*F in bathroom#1, and 111.2*F in batthroom# 2, which is within the Title 22, California Code of Regulations requirement
- A telephone for resident use was observed in the facility to be operational

LPA's Maldonado and Ramirez have cleared the physical plant.

An exit interview was conducted with applicants and a copy of this report was furnished. Accordingly, LPA's 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: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
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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