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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607361
Report Date: 05/17/2024
Date Signed: 05/17/2024 01:09:09 PM

Document Has Been Signed on 05/17/2024 01:09 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ROYAL PALMSFACILITY NUMBER:
197607361
ADMINISTRATOR/
DIRECTOR:
NATALIE MALLONFACILITY TYPE:
740
ADDRESS:20548 GERMAIN STREETTELEPHONE:
(818) 772-7153
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 6CENSUS: 6DATE:
05/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:John Mallon, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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At 09:15am, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with Staff #1, who granted access to the facility. Administrator arrived shortly after, and LPA explained the reason for the visit.

At 09:20am LPA conducted a tour of the physical plant and observed the following:

Facility is licensed for capacity of six (6) Non-Ambulatory residents. Facility also has a hospice waiver for one (1) resident. There are four (4) bedrooms designated for residents’ use, and one (1) bedroom, by the kitchen, is designated for a live-in caregivers. Bedrooms are appropriately furnished and have appropriate lighting. The hot water temperature measured at 120.0°F. Extra towels and linens were readily available. Bathrooms have soap, paper towels and hand washing signs were observed. Extra towels and linens were readily available. Facility maintains a temperature of 73°F. LPA observed there to be sufficient stock of one-week perishable foods and two-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. The fire extinguisher is located in the kitchen and was last serviced on 07/23/23. Laundry is located in a hallway, and LPA observed all chemicals and detergents are kept locked and inaccessible to residents in care. LPA observed a clean covered patio and backyard furniture to accommodate the six (6) residents. Smoke detectors and carbon monoxide monitors were tested at 10:30am and observed to be functional. Between 10:30am to 11:30am, LPA reviewed records of six (6) clients and two (2) staff. Resident and staff records appeared to be complete and updated. LPA collected Certificate of Liability Insurance and LIC500.

No citations issued during this visit.
Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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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