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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603565
Report Date: 08/16/2024
Date Signed: 08/16/2024 01:50:05 PM


Document Has Been Signed on 08/16/2024 01:50 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 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: 6DATE:
08/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Administrator Gregg KnappTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit and was greeted by Administrator Gregg Knapp. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be accessible to residents in private bathroom#2, located in resident bedroom#3. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observe postings encouraging proper handwashing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. Showers were observed to be wheelchair accessible.

Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C).

Planned Activities: LPA Ramirez observed puzzles, blocks, memory games and coloring books in living room area.

Residents Rights-Information: LPA Ramirez observed the following posting in common area of the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility line.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 03/06/24. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility.



See 809-D
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024
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 9


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 GARDENS 2
FACILITY NUMBER: 198603565
VISIT DATE: 08/16/2024
NARRATIVE
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Residents with Special Needs: No large bodies of water were observed. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order.

Health Related Services/Incidental Medical Services: The medications are centrally stored facility cabinet. LPA Ramirez observed three (3) containers of medication sitting on top of kitchen counter and accessible to residents and visitors. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA Ramirez observed six (6) out of the six (6) residents MAR did not reflect documentation of continuing medication care administered from 8/14/24 through 8/16/24 (AM only). The facility provides incidental medical services. LPA Ramirez observed six (6) out of the six (6) residents had their medications transferred from their original container and into a 7-day pill box organizer.

Staffing: Administrator Certificate for Gregg Knapp expires 06/16/2025. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for two (2) out of the three (3) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance for three (3) out of the three (3) personnel records reviewed. LPA Ramirez did not observe job applications for three(3) out of the three (3) personnel records reviewed.

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.



Operational Requirements: The fire clearance is approved for six (6) non-ambulatory. This facility may retain no more than three (3) hospice residents. There are three (3) residents under hospice care.

Resident Records/Incident Reports: LPA reviewed Resident files for six (6) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed for five (5) out of the six (6) residents in care. R2 did not have signed Admission Agreement, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, and Resident Rights. Some information was missing on these forms.
Deficiencies were observed today. Exit interview was conducted. A copy of this report, 809-D, LIC 9120 and appeals rights was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 08/16/2024 01:50 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: PEACEFUL GARDENS 2
FACILITY NUMBER: 198603565

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, disinfectants and cleaning solutions were observed to be accessible in private bathroom#2, the licensee did not comply with the section cited above in 2 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2024
Plan of Correction
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Licensee removed during visit to clear 24 correction. Licnesee will retrain staff on this regulatiuon by 8/23/24. Proof of retraining must be emailed by 8/23/24
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, 3 containers of medication were left on top of kitchen counter, the licensee did not comply with the section cited above in 6 out of 6 residnets and/or visitors which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2024
Plan of Correction
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Licensee removed during visit to clear 24 correction. Licnesee will retrain staff on this regulatiuon by 8/23/24. Proof of retraining must be emailed by 8/23/24
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024
LIC809 (FAS) - (06/04)
Page: 3 of 9


Document Has Been Signed on 08/16/2024 01:50 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: PEACEFUL GARDENS 2
FACILITY NUMBER: 198603565

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, medications were setup for 7 days in advance and not in their original container, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee will not transfer medications between containers. Licensee will retrain staff by 8/23/24. Proof of retraining must be emailed by 8/23/24
Type B
Section Cited
CCR
87506(b)(13)
Resident Records
(b) Each resident's record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or the services he needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, staff was not continuing record of medications administered from 8/14/24 through 8/16/24 (am only), the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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3
4
Licensee will retrain staff on this regulation by 8/23/24. Proof of retraining must be emailed by 8/23/24.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024
LIC809 (FAS) - (06/04)
Page: 4 of 9