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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005573
Report Date: 04/11/2024
Date Signed: 04/11/2024 09:14:56 AM

Document Has Been Signed on 04/11/2024 09:14 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:UNITED PEACE RESIDENTIAL HOMES 2FACILITY NUMBER:
306005573
ADMINISTRATOR/
DIRECTOR:		TA-PEREZ, MICHELEFACILITY TYPE:
735
ADDRESS:12792 ARLETTA CIRTELEPHONE:
(657) 251-0030
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 4CENSUS: 4DATE:
04/11/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Michelle Ta-PerezTIME VISIT/
INSPECTION COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit for the purpose of conducting a Plan of Correction (POC) inspection. LPA met with Administrator (AD) Michelle Ta-Perez and discussed the purpose of the inspection..

LPA is following up on deficiencies cited on 3/15/24, during a annual inspection. Deficiency 80075(k)(5) was cited due to client medication not being kept in its original containers and being pre-prepared a week in advanced in a weekly medication organizer or added to pre-package bubble pack medication. During today's visit, LPA confirmed all client medication is being kept in its original containers and is no longer being pre-prepared a week in advance. AD provided LPA with a signed copy of in-service for staff training conducted.

AD has met POC and deficiency previously cited will be cleared.

Based on today’s observations no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
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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