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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610402
Report Date: 08/23/2024
Date Signed: 08/23/2024 05:22:44 PM

Document Has Been Signed on 08/23/2024 05:22 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/
DIRECTOR:		TSANG, EVAFACILITY TYPE:
740
ADDRESS:20125 NEEDLES STREETTELEPHONE:
(818) 634-5782
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 6CENSUS: 4DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Eva Tsang, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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At 12:30pm Licensing Program Analyst (LPA), Angela Panushkina conducted an unannounced annual inspection at the facility mentioned above. LPA met with the staff and the Administrator was contacted via phone. The Administrator arrived shortly after and LPA explained the reason for the visit. Physical tour was conducted with the Administrator and LPA observed the following:

The facility has an approved fire clearance for six (6) bedridden and six (6) hospice residents.

Kitchen: At approximately, 1:05pm LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum one (1) week and perishable for two (2) days at the facility. All knives and sharps observed to be locked in the kitchen drawer. LPA observed a fully charged fire extinguisher in the kitchen.

Medications: At approximately, 1:10pm LPA observed medications are centrally stored and locked in a medication cart/cabinet. A fully stocked First Aid Kit was kept by the medication cart/cabinet.

Bedrooms: LPA observed total of five (5) bedrooms designated for clients use. Bedrooms #1, #2 #3 and #4 are private and bedroom #5 is shared. All bedrooms are properly furnished, clean and have appropriate bedding and linens. LPA also observed one (1) hospital bed (in room # 2) with full rail and two (2) hospital beds (in rooms #3 and #4) with ½ bed rails, without a written physician orders in place/on file.

Bathrooms: LPA observed two (2) bathrooms, and both appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and client's bathroom had non-skid mat. Hot water temperature measured at 119.1°F.

Continue on LIC 809C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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 4
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: 08/23/2024
NARRATIVE
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Common Areas: The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. The garage was locked and contained an extra refrigerator and freezer, paper supplies, incontinence supplies, and PPE. The garage was also used as a laundry room and LPA observed all the laundry detergent and other cleaning supplies to be locked and inaccessible to residents in care. LPA measured the room temperature to be 72°F. A fireplace in the living room was inaccessible and covered appropriately. Residents and staff were doing activities in the living room during the visit. Games, art materials, and television were provided.

Smoke detectors/carbon monoxide. Smoke detectors and carbon monoxide were located throughout the facility, and at 1:30pm they were tested and observed to be operational.

Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture with a covered patio for residents’ use.

Between 1:50pm to 3:00pm, LPA reviewed records of four (4) clients and one (1) staff.

Administrative: LPA attempted to collect Certificate of Liability Insurance but was informed by the Administrator that no insurance is available at this time.

Per the California Code of Regulations, Title 22, deficiencies are cited and noted on LIC-809D.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/23/2024 05:22 PM - It Cannot Be Edited


Created By: Angela Panushkina On 08/23/2024 at 02:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOUSE OF PEACE
FACILITY NUMBER: 197610402

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provision:
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not purchasing a Liability Insurance since license approval date of September 12, 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee shall purchase a liability insurance and a proof of insurance shall be submitted to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/23/2024 05:22 PM - It Cannot Be Edited


Created By: Angela Panushkina On 08/23/2024 at 03:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOUSE OF PEACE
FACILITY NUMBER: 197610402

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
87608(5)(A,B)
Postural Support: A half bed rail, extending from the head of the bed, can be used only for assistance with mobility. Bed rails that extend the entire length of the bed (full bed rails) are prohibited except for residents on hospice and their hospice care plan specifies the need.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by having a full bed rail in room #2 and 1/2 bed rails in room #3 and #4, without a written physician orders in place, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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During today's visit, Admisnitrator removed the full bed rail. If another postural support will be used the administrator shall ensure an order is obtained and placed on file from the physician indicating the need postural.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


LIC809 (FAS) - (06/04)
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