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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608129
Report Date: 05/22/2025
Date Signed: 05/22/2025 02:13:39 PM

Document Has Been Signed on 05/22/2025 02:13 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:RESIDENCES AT ROYAL BELLINGHAM, THEFACILITY NUMBER:
197608129
ADMINISTRATOR/
DIRECTOR:		LORI MCKAYFACILITY TYPE:
740
ADDRESS:12229 CHANDLER BOULEVARDTELEPHONE:
(818) 980-2997
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY: 96CENSUS: 91DATE:
05/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Lito Vitug - Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 10:45AM for a required one-year visit. Executive Director (ED) Lito Vitug arrived at 11:54AM, met with LPA Huynh and LPA explained the reason for the visit. Entrance interview conducted.

At 12:05PM, the LPA and ED 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. The following was observed:

RESIDENT ROOMS: The LPA observed ten (10) randomly selected rooms with private restrooms on the first and second floor and no immediate health or safety hazards were observed. Restrooms were clean, with properly installed grab-bars in resident bathrooms and non-skid strips in showers. Resident rooms were furnished with all required furniture within regulation. Water temperature was tested throughout the units and measured between 113.7 degrees F and 120 degrees F, which is within the required range per regulation.

Report Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: RESIDENCES AT ROYAL BELLINGHAM, THE
FACILITY NUMBER: 197608129
VISIT DATE: 05/22/2025
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COMMON AREAS: The facility is a two-story building with a total of eighty-eight (88) units. On the first floor, there are the kitchen facilities, dining room, laundry room, emergency food and water storage, lobby, outdoor lobby/smoking area, medication room, staff offices, common restrooms, and outdoor courtyard. On the second floor, there are common restrooms, a conference room, a library, and common/activity space. The LPA observed common areas to be clean and contain furniture in good condition. There were no obstructions and/or tripping hazards throughout the facility. There were cameras in the common areas, outdoor courtyard, and exterior perimeter. Required postings were found in the hallways on the first floor. LPA observed electric stair lifts in the staircases in the event of an emergency and elevators are out of order. There were no bodies of water observed during today’s visit. There are fire extinguishers throughout the facility, which were serviced 03/13/2025. Fire alarm system is tested annually with the last inspection on 11/26/2024 and a retest on 05/06/2025 by Advance Building Protection.

KITCHEN: There is one kitchen located on the 1st floor attached to the dining room. Facility dining room and commercial kitchen were inspected and in compliance with Title 22 regulations. Facility receives food deliveries twice a week from Costco and F&W food services. There was a sufficient supply of perishable and non-perishable food. Food appeared to be of good quality and labeled appropriately. Emergency food and water are stored in the hallway closet nearby the dining room.

EMERGENCY DISASTER: LPA reviewed the facility's Disaster plan at 1:20PM. LPA noted that the facility is in compliance with regulation. Facility conducts emergency disaster drills as required with drills conducted quarterly.

Report Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: RESIDENCES AT ROYAL BELLINGHAM, THE
FACILITY NUMBER: 197608129
VISIT DATE: 05/22/2025
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Six (6) staff, twelve (12) residents, and one (1) family member of a resident were interviewed throughout the duration of the visit. No complaints or immediate safety concerns noted.

Due to time constraints, LPA Huynh will return at a later date for an Annual continuation.

Documents obtained: LIC 500 Personnel Report, Resident Roster, Emergency Disaster Plan, and most recent Fire Inspection.

No deficiency cited. Exit interview conducted. A copy of today’s report was reviewed and provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
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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