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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609001
Report Date: 05/28/2022
Date Signed: 05/28/2022 12:53:46 PM

Document Has Been Signed on 05/28/2022 12:53 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:ROYALTY ASSISTED LIVINGFACILITY NUMBER:
197609001
ADMINISTRATOR:AVETIAN, LIDUSHFACILITY TYPE:
740
ADDRESS:10940 STRATHERN STREETTELEPHONE:
(818) 436-9088
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 10CENSUS: 13DATE:
05/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Kara CharchaogalyanTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management visit, in conjunction with delivering the final report for complaint control # 31-AS-20210903103926. During the visit, LPA observed the structure of the facility to be altered. According to the caregiver, Kara, who confirmed to the LPA the facility had been changed and an additional room was added to the facility. LPA inquired how many residents were currently at the facility, and it was confirmed that the facility had (13) residents at the time of the visit. The capacity is 10; and the facility is over capacity. An immediate civil penalty of $500 will be issued, due to being over capacity and not having a fire clearance for having the amount of residents in the facility.

LPA will also issue a citation for facility not notifying Licensing regarding the alteration of the facility and not obtaining a proper fire clearance, as well not submitting the proper documents to Licensing for the alteration, such as a new facility sketch and building permits.

Administrator was also informed that they need to submit in writing there intention and future plans for the extra room that were added to the facility. Building permits also need to be submitted to LPA within (5) business days (due June 07, 2022).

LPA spoke to both Administrators, Estella and Lidush Avetian, via cellphone, regarding the citations and civil penalty that was issued during today's visit. Both could not be present, and requested that caregiver Kara sign documents, and email them to Administrator.

Exit interview, appeal rights, and copy of report will be emailed.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2022
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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Document Has Been Signed on 05/28/2022 12:53 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 05/28/2022 at 11:45 AM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYALTY ASSISTED LIVING
FACILITY NUMBER: 197609001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/29/2022
Section Cited
CCR
87202(a)

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All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the
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Administrator has AGREED to notify LPA by 05/29/2022, informing LPA how she will relocate the (3) residents that are at the facility.
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following types of persons...the applicant or licensee shall notify the licensing agency..This requirement was not met, evidenced by, LPA observed (13) residents at the facility with only having a capacity for (10). This is an immediate health and safety risk to residents in care.
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Type A
05/29/2022
Section Cited
CCR87305(a)

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Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met, evidenced by: LPA observed the facility had been altered
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Adminstrator (Estella) has AGREED to contact LPA regarding the building permits by POC date. Further, the Administrator will obtain a proper fire clearance, new facility sketch, and submit documentation to Licensing
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and the facility did not provide the building permits or new facility sketch to LPA. This is an immediate health and safety risk to residents in care.
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regarding future plans of what the added room will be used for, and submit copies of the building permits to LPA with (5) days of today's date.
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:Cassandra Harris
LICENSING EVALUATOR NAME:Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2022


LIC809 (FAS) - (06/04)
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