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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609801
Report Date: 07/23/2021
Date Signed: 07/23/2021 10:54:35 PM

Document Has Been Signed on 07/23/2021 10:54 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:LAND OF PEACE 5FACILITY NUMBER:
197609801
ADMINISTRATOR:ROSELIN FINULIARFACILITY TYPE:
740
ADDRESS:22625 KITTRIDGE STREETTELEPHONE:
(818) 883-3356
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: DATE:
07/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Staff Kelvin KapendaTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) LaQueena Lacy arrived at the facility at 11:25am to conducted a One (1) year Required Infection Control visit. LPA meet with the designated staff kelvin and explained the purpose of this visit. A tour of the physical plant was conducted at 11:30am and the following was observed:

The facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette and physical distancing). The PPE screening station is located at the front door on an end table equipped with sufficient PPE readily accessible a thermometer, hand sanitizer, gloves, mask and sign in sheet at the time of visit. Visitors are not allowed in the facility at this time. The Fire Extinguisher is located on the wall in the laundry room purchase dated May 13, 2021. The fire alarm system is hard wired and inter connected. The facility has five bedrooms (5) one (1) room is designated for Staff. Three bathrooms (3) one (1) of the bathrooms are located in room five (5).

The facility has an approved mitigation plan on file.

Medication: The medication is located in the kitchen cabinet which was observed to be locked and inaccessible to residents.

Kitchen: The kitchen was observed to be clean and an inadequate supply of perishables and non-perishable food, currently the licensee has a off site food waiver in which a outside food vendor provides meals for the residents. The perishable, non-perishable and emergency food is stored in one (1) central location off site on the sister property of the facility. Breakfast is prepared in the facility, lunch and dinner are catered by the off site vendor. Sharps were observed to be locked and inaccessible to residents.

(Continued on LIC 809C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LAND OF PEACE 5
FACILITY NUMBER: 197609801
VISIT DATE: 07/23/2021
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Resident rooms: There are six (6) bedrooms and one (1) is designated for staff which is located across from room one (1) and room two (2). All bedrooms observed to be clean with adequate furniture, appropriate bedding, linens and sufficient lighting.
Bathrooms: LPA observed three (3) bathrooms in which one (1) is located in room five (5) to be clean and in proper operation with appropriate hand washing signs posted in each bathroom. LPA observed the appropriate grab bars in and around the toilet and shower and non-skid mats located in the shower area. At 12:11pm the hot water temperature measured in range of 105.5 to 111.4. Towels and washcloths are not shared. Residents have sufficient amounts of supplies for personal hygiene which is provided by the Licensee.
Outside areas: LPA toured the outside area of the facility which provides a covered patio area with appropriate outdoor furniture for residents also located in front yard of the facility under a shaded tree. There are no bodies of water located on the premises.
Laundry Room: At 12:25pm LPA observed toxins, laundry soap and other cleaning supplies locked in a cabinet located in the laundry room adjacent to the kitchen. There is enough linen available to change weekly or more if needed.
Administrative: LPA collected the Administrators certification, Sample food menu, certificate of liability insurance and LIC 500. Annual fees are current.


Exit interview conducted. Copy of this report issued




SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
LIC809 (FAS) - (06/04)
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