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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609929
Report Date: 01/10/2024
Date Signed: 01/10/2024 04:51:05 PM

Document Has Been Signed on 01/10/2024 04:51 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:A PEACE OF HOMEFACILITY NUMBER:
567609929
ADMINISTRATOR:PEREY, HERBERT M.FACILITY TYPE:
740
ADDRESS:1227 MIKA WAYTELEPHONE:
(805) 278-9620
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 6CENSUS: 2DATE:
01/10/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Herbert PereyTIME COMPLETED:
12:22 PM
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual continuation visit. LPA met with Administrator Herbert Perey and explained the reason for the visit.

The LPA completed record review and medication review.

STAFF RECORDS: LPA reviewed staff records for two staff. Training was complete. All staff have CPR/First Aid certifications. All staff scheduled to work at the facility are fingerprint cleared and associated to the facility.

RESIDENT RECORDS and MEDICATION: LPA reviewed two residents' records. Resident files included pre-admission appraisals, needs and services plans, physician's reports, and admission agreements. Medications appear to be given as prescribed based on review of medications and the centrally stored medication and destruction records.

EMERGENCY DISASTER PLAN: The emergency disaster plan was complete. The facility conducts disaster drills quarterly on each shift.

LPA interviewed two staff; there were no concerns.

LPA attempted to interview two residents. One resident was unable to answer questions due to their condition and one resident was sleeping.

No deficiencies observed during today's visit. Exit interview conducted. Report emailed to Administrator.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2024
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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