197603385-5-22-2025-28-AS-MGFS-DGWQH8-20250522121043

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603385
Report Date: 05/22/2025
Date Signed: 05/22/2025 12:10:56 PM

Document Has Been Signed on 05/22/2025 12:10 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	COMMONWEALTH ROYALE GUEST HOME		FACILITY NUMBER:	197603385
ADMINISTRATOR/ DIRECTOR:	MAYA MNOYAN		FACILITY TYPE:	740
ADDRESS:	150 S. COMMONWEALTH AVE		TELEPHONE:	(213) 382-6381
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90004
CAPACITY: 99		CENSUS: 91	DATE:	05/22/2025
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Zara Poghosyan - Executive Director		TIME VISIT/ INSPECTION COMPLETED:	12:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	LIcensing Program Analyst (LPA)s Mary Flores and Blanca Gonzalez conducted an unannounced case management visit to follow up on capacity increase request submitted to the department on 8/21/24. LPAs met with Zara Poghosyan and explained the reason for the visit. The facility is currently licensed to serve 99 non-ambulatory residents over the age of 60, of which 14 may be non-ambulatory in rooms #101,102,103,104,105,106,107,122 (rooms #101 and 122 are allowed only 1 non-ambulatory resident). The facility is located in a residential area and consist of a two level building with two dining rooms, a lobby area, a commercial kitchen, a courtyard, an activity room, several rooms, front patios, and a garage area in the back. No changes have been done to the building. The capacity increase will take place by changing current bedrooms into shared resident bedrooms. The Fire Clearance was granted on 4/17/25 for 92 ambulatory residents and 14 non-ambulatory residents over the age of 60. The facility does not serve dementia residents and does not have a memory care unit. LPA toured the facility with Zara Poghosyan and observed common areas, kitchen, and the following resident rooms: #103,105, 111,115,119, 204, 210, 215,218 which were randomly chosen. Room #218 was observed currently being used as storage for linens. Rooms #204, 210, 215,218 have lighting. However, bulbs were very dim and do not light up the entire room. Additional lighting is required. Shower curtain in room #210 was observed ripped. Room #215 was missing side grab bar near the shower. Resident #1(R1)'s bed was observed with half bed rails on one side of the bed and a large box per the residents initiative to obtain privacy in room #119. Dining room floor by the entrance has a rise of about a 2ft by 3ft with a height of about 4 inches from ground level. Facility has a camera system to allow entry to the facility to residents and staff by facial recognition. (CONTINUED ON LIC 809C)

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: COMMONWEALTH ROYALE GUEST HOME	FACILITY NUMBER: 197603385
	VISIT DATE: 05/22/2025

NARRATIVE

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Guest and visitors may call the receptionist to gain entry into the facility using the same system. Residents have signed a surveillance acknowledgment and may refused to participate. The main door does not open from the outside but opens from inside to allow exit of the facility. Passageways exit doors have a code which the staff are trained and have access to exit in case of an emergency. Codes and facial recognition have been place due to security reasons.

Administrator will make the following corrections and will submit pictures to the department within 10 days:

Will remove the items and ensure room #218 is ready for residents to move in.
Will provide sufficient lighting to rooms #204,210,215,218.
Will provide shower curtain in room #210.
Will provide additional grab bar in room #215's shower.
Will provide proper privacy means for resident R1 in share bedroom #119.
Will fix the dining room floor.
Will submit a sketch of the facility which notes non-ambulatory rooms.

LPA was provided an updated LIC 200 during this visit. LPA will return at a different time to follow up on the items above.

Exit interview was conducted and a copy of this review was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC809 (FAS) - (06/04)

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