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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610402
Report Date: 08/25/2023
Date Signed: 08/25/2023 12:50:18 PM

Document Has Been Signed on 08/25/2023 12:50 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:HOUSE OF PEACEFACILITY NUMBER:
197610402
ADMINISTRATOR:TSANG, EVAFACILITY TYPE:
740
ADDRESS:20125 NEEDLES STREETTELEPHONE:
(818) 634-5782
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 6CENSUS: 0DATE:
08/25/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Eva Tsang, Administrator TIME COMPLETED:
01:00 PM
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At 10:30am Licensing Program Analysts (LPAs), Angela Panushkina and Christopher Alemoh conducted an announced Pre-Licensing visit to the above facility and met with the Administrator.

Fire Clearance was approved on 04/17/2023 for a maximum capacity of six (6) residents, of which five (5) Non-Ambulatory and one (1) bedridden residents. Hospice waiver for six (6) residents was approved on 02/21/23.

The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPAs touring the physical plant inside and outside and observed the following:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. At 10:40am, LPAs observed adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. Fire Extinguisher was last serviced on 03/27/2023.


BEDROOMS: There are four (4) bedrooms designated for client use. All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. All exit door will have an auditory alarm. Staff bedroom #4 is located by the living room.

BATHROOMS: At 10:50am, LPAs observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 119.3°F.

COMMON AREAS: The facility maintains a comfortable temperature at 70°F. The living room and dining area
Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2023
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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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: HOUSE OF PEACE
FACILITY NUMBER: 197610402
VISIT DATE: 08/25/2023
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appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility.

MEDICATION: All medications will be kept in a locked cabinet located by the dining area.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 11:00am they were tested and observed to be operational.


LAUNDRY ROOM: The laundry room is located in a garage and was observed to be locked and inaccessible to residents in care.

SURROUNDING GROUNDS: The backyard has sufficient yard space. LPAs observed appropriate outdoor furniture, with a covered shaded area for clients. LPAs discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water.

Component III was conducted with the Administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted and with a copy of this report was provided to the Applicant/Administrator
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC809 (FAS) - (06/04)
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