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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609929
Report Date: 12/08/2023
Date Signed: 12/08/2023 02:11:48 PM


Document Has Been Signed on 12/08/2023 02:11 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
WOODLAND HILLS N.ASC, 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: 3DATE:
12/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:17 AM
MET WITH:Herbert PereyTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 8:17 a.m. LPA met with Administrators Mischelle Perey and Herbert Perey and explained the reason for the visit.

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 4/24/2023. KITCHEN: 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 and emergency water. Hot water temperature measured 119.8*F. BEDROOMS: The LPA observed two double-occupancy bedrooms and two single-occupancy bedrooms which were clean and furnished appropriately. RESTROOMS: The two restrooms were 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 residents' 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: 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.

LPA will return at a later date to continue this annual inspection.

No deficiencies observed during today's visit. Exit interview conducted. Report emailed to Administrator.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023
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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