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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603521
Report Date: 01/18/2022
Date Signed: 01/18/2022 12:13:28 PM

Document Has Been Signed on 01/18/2022 12:13 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:A PEACEFUL HOME OF COVINAFACILITY NUMBER:
198603521
ADMINISTRATOR:BUGASTO, MYRNA G.FACILITY TYPE:
740
ADDRESS:16025 E BRIDGER ST.TELEPHONE:
(626) 244-9999
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 0DATE:
01/18/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Thang Duong, ApplicantTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Tao conducted an announced visit for pre-licensing follow up inspection. The applicant notified the department for visit since corrections were made. The initial pre-licensing visit was conducted on 01/22/2022. LPA met with applicant, Thang Duong, to discuss the purpose of today's visit and the inspection.

During this visit, LPA observed the following corrections:
- Medication cabinet is installed with a key lock.
- Kitchen drawer containing sharp objects (knives, scissors and etc) is installed with a key lock.
- Water heater closet is secured with a key lock
- Cleaning supply, linen, and toxin closet on far end of hall is secured with a key lock.
- Five bedrooms have a keyless lock doorknobs.
- The dead-bolt on fire door leading to four resident bedrooms/bathroom has been removed.
- Toxins and gardening tools in backyard are stored in garages and inaccessible to residents.
- Sliding screen leaning on wall in the backyard is removed.
- Auditory alarm device on sliding glass door leading to backyard is operable.
- Sufficient supply of linen, bed sheets, blankets, pillows, and towels are observed.
- Hot water temperature is measured at 110.1 degrees Fahrenheit.

Component III was conducted with applicant during the initial visit on 1/22/22.

No further corrections are needed.

Exit interview held and copy of the report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2022
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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