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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423576
Report Date: 02/08/2023
Date Signed: 02/08/2023 03:25:12 PM

Document Has Been Signed on 02/08/2023 03:25 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:PEACEFUL LIVING #2FACILITY NUMBER:
336423576
ADMINISTRATOR:RUSH, JOEFACILITY TYPE:
735
ADDRESS:1112 PEACEFUL DRIVETELEPHONE:
9515318134
CITY:CORONASTATE: CAZIP CODE:
92880
CAPACITY: 6CENSUS: 3DATE:
02/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Lena Rush, AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Amy Goldenberg is conducting this case management visit to follow up on a self reported incident pertaining to C1 and to conduct a health and safety check in the home. During this visit LPA met with three (3) of three (3) clients residing in the home. LPA toured the facility, checked the food supply and spoke with the facility administrator about the incident. LPA learned that the incident, which reports possible sexual assault, would have occurred outside of the home and did not involve facility staff, but a friend that C1 met up with outside of the home. C1 confirmed the incident did not involve any one in the home.

LPA has not identified any health and safety concerns in the home. Interviews did not reveal any concerns. This report was reviewed with and a copy was provided to Lena Rush, Licensee.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2023
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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