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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530026
Report Date: 11/27/2023
Date Signed: 11/30/2023 03:49:12 PM

Document Has Been Signed on 11/30/2023 03:49 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:PRINCE OF PEACE CORPORATIONFACILITY NUMBER:
335530026
ADMINISTRATOR:OLADIMEJI, OLUWATOYINFACILITY TYPE:
735
ADDRESS:12658 DUTCH COURTTELEPHONE:
(678) 622-6131
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 4CENSUS: 0DATE:
11/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Oluwatoyin Oladimeji, Administrator/LicenseeTIME COMPLETED:
12:15 PM
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1100: Licensing Program Analyst (LPA) Amy Goldenberg arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility representative with LPA identification and business card. LPA learned that the facility currently does not have any residents or employees. No employee or client interviews were conducted.

LPA toured the facility inside and outside. LPA observe the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature measured 115 degrees F. Grab bars, non slip mats are present in the restrooms. Laundry facilities and a locked cabinet is present and a space for storing laundry soap and other chemicals in the garage. Fire extinguishers are charged, mounted. All outdoor and indoor passageways are free of obstruction. Night lights and emergency lighting is present. A locked area is provided for medications and sharp objects. There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. The facility has a current written definitive plan of operation. The facility is maintained in conformity with the regulations adopted by the state fire marshal. There are currently no clients or employee records to review. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand.

Based on the information received during this visit today, there are no deficiency is being cited per Title 22, Division 6 of The California Code of Regulations.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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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