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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603385
Report Date: 10/30/2025
Date Signed: 10/30/2025 05:11:42 PM

Document Has Been Signed on 10/30/2025 05:11 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 HOMEFACILITY NUMBER:
197603385
ADMINISTRATOR/
DIRECTOR:		MAYA MNOYANFACILITY TYPE:
740
ADDRESS:150 S. COMMONWEALTH AVETELEPHONE:
(213) 382-6381
CITY:LOS ANGELESSTATE: CAZIP CODE:
90004
CAPACITY: 106CENSUS: 81DATE:
10/30/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Zara PoghosyanTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sakinah Madyun conducted an unannounced Case Management visit to facility to check the health and safety of residents in care. LPA met with Director Zara Poghosyan and Administrative Assistant Diana Rios and explained the reason for today's visit.

At 9:45am LPA discussed incident in question regarding medication error in which Wellness Director Ambresa Bree Thomas was contacted via phone to assist with information.

At 10:00am - 1:15pm LPA reviewed Residents (R1 and R2) Electronic Medication Administration Records (EMAR). Director, Administrative Assistant, and Wellness Director assisted during review. Based on record review and interviews the following errors were found:


  • R1 was given the prescription medication on September 25, 2025 by MedTech.
  • R1 was given medication that was prescribed for R2 by MedTech.
  • Medication error was not discovered until a week later. Upon distribution R2's scheduled prescription medication was discover missing.
  • Medication is listed on residents Face Sheet and Emergency Information Sheet (Info) and EMAR system. The medication for both (R1) and (R2) are alike but have different milogram dosages.

The requirement was not met by Title 22 Regulation and resulted in a medication given in error.
Deficiency is cited per California Title 22, Division 6 Chapter 8. See LIC 809D.
Exit interview was conducted with Director Zara Poghosyan. A copy of the report and appeal rights was
provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Sakinah Madyun
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2025
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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Document Has Been Signed on 10/30/2025 05:11 PM - It Cannot Be Edited


Created By: Sakinah Madyun On 10/30/2025 at 04:16 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: COMMONWEALTH ROYALE GUEST HOME
FACILITY NUMBER: 197603385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2025
Section Cited
CCR
87465(a)(1)

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87465(a)(1)-
(a) A plan for incidental medical and dental care shall be developed by each facility...
(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.This requirement was not met as evidenced by:
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The Administrator is to have an in service training on medication protocol to ensure future medication errors do not occur. The training shall include a plan that illustrates steps the facility will take to prevent future errors.
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Based on record review and interviews R1 was given the prescription medication on September 25, 2025 by MedTech.
R1 was given medication that was prescribed for R2 by MedTech.
Medication error was not discovered until a week later. Upon distribution R2's scheduled prescription medication was discovered missing.
Medication is listed on residents Face Sheet and Emergency Information Sheet (Info) and EMAR system. The medication for both (R1) and (R2) are alike but have different milogram dosages.
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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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Sakinah Madyun
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2025


LIC809 (FAS) - (06/04)
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