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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609801
Report Date: 07/23/2024
Date Signed: 07/23/2024 02:48:06 PM

Document Has Been Signed on 07/23/2024 02:48 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:LAND OF PEACE 5FACILITY NUMBER:
197609801
ADMINISTRATOR/
DIRECTOR:		ROSELIN FINULIARFACILITY TYPE:
740
ADDRESS:22625 KITTRIDGE STREETTELEPHONE:
(818) 883-3356
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 6DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Roselin FinuliarTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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At 9:10 a.m. on 07/23/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, annual inspection. LPA met with the administrator and disclosed the reason for the visit.

The facility was last visited on 08/31/23 for a complaint visit. It is a single story building with six (06) bedrooms, three (03) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) residents, of which five (05) may be non-ambulatory and one (01) bedridden in Bedroom #4. The facility serves residents with dementia. Approved hospice waivers for six (06).

LPA and administrator toured the facility inside and out. The front yard was maintained. At the main entrance, LPA observed postings for the facility license, rights of resident councils, personal rights, resident rights, emergency disaster plan, emergency contacts, confidential complaint contacts, ombudsman contacts, neighborhood complaint policy, house rules, administrator certificates, and a blank copy of the admission agreement. A sign indicating "No smoking - Oxygen in use" was posted on the front door.

The facility has six (06) bedrooms. One (01) bedroom is designated as a staff room. The staff room was free of hazards. All bedrooms contained a chair, nightstand, lighting, storage, and a bed with adequate bedding. All furnishings were clean and in good condition.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:15 a.m. LPA measured the room temperature to be 79 degrees Fahrenheit. The living room contained board games, puzzles, reading material, a television, and furniture in good condition. The fireplace was appropriately covered. Four (04) residents were observed relaxing in the living room. Cameras were observed in common areas.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LAND OF PEACE 5
FACILITY NUMBER: 197609801
VISIT DATE: 07/23/2024
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LPA observed an adequate supply of perishable and non-perishable foods in the kitchen and the garage. The stove hood was clean. Appliances were in good condition. At 10:35 a.m. the freezer was observed to be zero (00) degrees Fahrenheit. At approximately 10:40 a.m. LPA observed a fully charged fire extinguisher near the kitchen. It was last inspected on 03/28/24. Sharps were locked by the refrigerator. Cleaning solutions were locked above the washer and dryer. Medications were locked above the counter top. The washing machine and dryer were both were in working order.

LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition. The ramp leading out was free of debris and had sturdy rails.

The facility has three (03) bathrooms. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 10:50 a.m. LPA measured the water temperature in the shared bathroom to be 109.1 degrees Fahrenheit.

Two (02) out of two (02) emergency exit paths were free from obstructions. Evacuation routes were posted. Three (03) out of three (03) auditory alarms were turned on and functioning. At approximately 11:00 a.m., smoke and carbon monoxide detectors were tested and operational. Detectors functioned simultaneously, and the fire door in the hallway closed securely.

During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed during today’s visit.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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