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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609929
Report Date: 11/30/2022
Date Signed: 12/01/2022 09:11:40 AM


Document Has Been Signed on 12/01/2022 09:11 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:A PEACE OF HOMEFACILITY NUMBER:
567609929
ADMINISTRATOR:PEREY, HERBERT M.FACILITY TYPE:
740
ADDRESS:1227 MIKA WAYTELEPHONE:
(805) 278-9620
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY:6CENSUS: 5DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Herbert PereyTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 9:35 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA initially met with caregiver Soliman Labrado who assisted with the physical plant tour. Administrator Herbert Perey was at an appointment and arrived at the facility at 10:36 a.m. Co-Administrator Michelle Perey was reachable by phone but out of town. LPA explained the reason for the visit to all parties.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher appeared fully charged and was last inspected on 4/20/2022. KITCHEN: Caregivers were preparing breakfast so some locks on cabinets were open. LPA observed knives are stored in a locked drawer and chemicals are stored in a locked cabinet under the sink. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of perishable and non-perishable food. BEDROOMS: The LPA observed two double-occupancy bedrooms and two single-occupancy bedrooms. RESTROOMS: Restrooms are clean and sanitary and in operating condition. COMMON SPACES: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The LPA observed the required postings throughout the facility. The backyard patio is equipped with furniture for clients' use. The garage and laundry room were locked. There is additional food stored in the refrigerator in the garage along with refrigerated medication. Medication is also stored in a locked cabinet in the living room. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. All facility staff were observed wearing masks. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff showing symptoms of COVID or testing positive for COVID.

No deficiencies observed. Exit interview conducted. Report emailed to Administrator.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
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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