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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191502216
Report Date: 11/09/2021
Date Signed: 11/12/2021 10:21:36 AM

Document Has Been Signed on 11/12/2021 10:21 AM - 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:ROYAL OAKSFACILITY NUMBER:
191502216
ADMINISTRATOR:GREGORY D BEARCEFACILITY TYPE:
741
ADDRESS:1763 ROYAL OAKS DRIVETELEPHONE:
(626) 359-9371
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY: 250CENSUS: 166DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director Andrew SmithTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPAs) Nina Galarza and Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPAs met with Executive Director Andrew Smith and stated the purpose of the visit.

The facility is licensed to serve for a capacity of two hundred fifty (250) residents ages 60 and above. A maximum of 25 Non-Ambulatory residents in the Bradbury Oaks building. The facility has an approved Hospice Waiver on file for four (4) residents. The facility also has an approved Dementia Care plan as part of their operation. This is a Continuing Care Retirement Community (CCRC) which includes three separate levels of care; Independent Living, Assisted Living and Skilled Nursing. The Assisted Living residents reside on the second floor of the Bradbury Oaks building. There are currently 27 residents in Assisted Living and 139 in Independent Living. The wander guard system is used in the Bradbury Oaks building (second floor) for residents diagnosed with dementia, who have wandering behaviors.

LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. During the tour, LPAs were accompanied by Executive Director and Sev Tienda, Director of Wellness. The second floor of the Bradbury Oaks building consists of a dining room, kitchen, resident rooms, computer room, library, television room, coffee room, medication room, laundry room, storage room, janitor's room, and a greenhouse area (used for planting).

LPAs toured a random selection of resident rooms. Resident rooms were furnished appropriately. Each resident room has their own restroom. The bathrooms were observed to be clean and operational w/grab bars. The resident rooms have a signal system located by the resident bed and in the restroom. The signal system was tested in various locations and is operable. The hot water temperature was tested throughout the facility and did not meet Title 22 Regulation guidelines.
CONTINUED 809-C
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ROYAL OAKS
FACILITY NUMBER: 191502216
VISIT DATE: 11/09/2021
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 detectors were observed to be fully charged and in compliance. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. The kitchen, food supply and emergency food and water supply were observed. There was a sufficient amount of perishable and non-perishable food supplies. No pesticides or poisons were stored in the food areas. Medications are centrally stored in the locked medication room located on the second floor. A random selection of medications were reviewed to ensure they are being administered as prescribed and prescription and non-prescription PRN medications have signed and dated written orders from the physician. All required information (Emergency Exiting Floor Plan, Personal Rights, Ombudsman information, Theft and loss policy and Emergency Telephone Numbers) are posted in the facility.

The following deficiencies were observed during today's visit;

- At 10:00 a.m. LPAs observed water temperature in room F111 at 121.3 degrees Fahrenheit
- At 11:45 a.m. LPAs tested the wander guard system and observed it to be inoperable near the exit doors leading to the kitchen and outside area making it a hazard for dementia residents with wandering behaviors.


The following deficiencies were observed to be in violation under California Code of Regulations Title 22.
(refer to 809D).
An exit interview was conducted and a copy of this report was provided to Sev Tienda along with the appeals rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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Document Has Been Signed on 11/12/2021 10:21 AM - It Cannot Be Edited


Created By: Nina Galarza On 11/09/2021 at 12:38 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ROYAL OAKS
FACILITY NUMBER: 191502216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 10:00 a.m. LPAs observed water temperature in room F111 at 121.3 degrees Fahrenheit. Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2021
Plan of Correction
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Administrator will provide picture proof of water temperature in room F111to be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C) to LPA Nina Galarza via text message by POC date.
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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- At 11:45 a.m. LPAs tested the wander guard system and observed it to be inoperable near the exit doors leading to the kitchen and outside area making it a hazard for dementia residents with wandering behaviors.
Based on observation, the licensee did not comply with the section cited above in, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2021
Plan of Correction
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Deficiency was corrected at time of visit. No further action needed.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nina Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021


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