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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609812
Report Date: 05/05/2022
Date Signed: 05/05/2022 01:36:21 PM

Document Has Been Signed on 05/05/2022 01:36 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 3FACILITY NUMBER:
197609812
ADMINISTRATOR:SONA MURADYANFACILITY TYPE:
740
ADDRESS:22600 KITTRIDGE STREETTELEPHONE:
(818) 704-7733
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 5DATE:
05/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sona MuradyanTIME COMPLETED:
01:45 PM
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At 11:30 a.m. on 05/05/2022 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with Administrator and disclosed the reason for the visit.

The reason for the visit comes from an incident report submitted on 05/04/2022. Resident #1 (R1) was admitted on 04/29/2022 with pressure injuries on the buttocks and left heel of unknown stages. During a 04/28/2022 hospital visit, a Kaiser physician informed the R1 and R1’s family that the wound on the heel would not prohibit admission to a board and care. The physician did not disclose the size or stage of the wounds but arranged a 05/05/2022 podiatry appointment. Home health also evaluated the wounds on 05/03/2022, but additional follow up was required for staging and treatment.

Regional Office has requested a full investigation by the Investigations Branch. The referral is currently pending.

At approximately 12:30 p.m. LPA interviewed Administrator.

At 12:51 p.m. LPA conducted a record review. LPA obtained copies of the register of facility residents, personnel report, staff training records, and medical assessment. Administrator will send additional information through email later today.

At 1:20 p.m. LPA and 2 Administrators conducted a physical plant tour with Administrator. R1 was in bed in an elevated position. R1 was safe and in good health. Administrator and staff redressed the wound. 2 photographs of the wound were taken.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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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