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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609001
Report Date: 09/13/2022
Date Signed: 09/13/2022 02:48:34 PM

Document Has Been Signed on 09/13/2022 02:48 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: 11DATE:
09/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Estella Avetyan & Lidish AvetianTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced case management visit, in regards to information obtained: the facility continues to be over capacity; residents are being out locked out of the facility, and a camera is located in a resident's room. Previously, LPA conducted a case management on 05/28/2022, in regards to delivering a complaint, for control # 31-AS-20210903103926. During that visit, LPA observed the structure of the facility, had been altered, and an additional room had been added to the facility. LPA also observed during that visit, the facility was over capacity and had (13) residents.

On June 06/03/2022, LPA Wendell Smith conducted and completed a complaint investigation, with control # 31-AS-20220601123035, in regards to the facility being over capacity with (13) residents. A deficiency and citation was issued. LPA T. Cabiness received information regarding the facility, and today's visit was to address the issues and concerns.

From 1245pm to 315pm, LPA conducted a physical plant inspection and interviewed resident and staff. LPA visually observed and counted (11) residents. LPA also observed a camera installed in the altered room. LPA interviewed residents, and it was reported the facility continues to lock the front gate, and residents are not allowed to leave freely, and staff have to open the front door in order for them to exit the front gate. This is a personal rights violation and citation will be issued today.

Licensee Lidish Avetian and Co-Administrator Estella Avetyan arrived to the facility at 130pm. LPA discussed the concerns and citations during today's visit.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 197609001
VISIT DATE: 09/13/2022
NARRATIVE
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LPA will discuss with management regarding the alteration of the facility and not obtaining a proper fire clearance, as well submitting the proper documents to Licensing for the alteration, such as a new facility sketch and building permits. This is an immediate heath and safety risk to residents in care.

Exit interview, appeal rights, and copy of report will be emailed.

Licensee maybe contacted for possible non-compliance plan (NCC) due to the serious citations and deficiencies that have been issued.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/13/2022 02:48 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 09/13/2022 at 01:41 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYALTY ASSISTED LIVING
FACILITY NUMBER: 197609001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2022
Section Cited
CCR
87204(a)

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Limitations-Capacity and Ambulatory Status-A licensee shall not operate a facility beyond the conditions and limitations...including specification of the maximum number of persons who may receive services at any one time. This requirement is not met as evidenced by:
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Co-Administrator Estella Avetyan will contact LPA on 09/14/2022 regarding the plan to relocate (1) client from the facility. Facility must be in compliance by the POC date...09/14/2022
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Based on observation and interviews facility has thirteen residents which is more than the ten residents the facility is licensed for which poses an immediate health and safety issue for all residents in care.
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Type B
09/27/2022
Section Cited
CCR87468.1(a)(6)

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Personal Rights of Residents in All Facilities . (a)Residents...shall have all of the following personal rights...(6)To leave or depart the facility at any time and to not be locked into any room, building, or
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Administrators will develop a system for residents to be able to leave the front gate freely without it being locked. Residents will either be provided a front key to eave, or the facility must implement a better plan
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on facility premises by day or night. This requirement was not, evidenced by, based on interviews and today's visit, the facility continues to lock the inside knob of the front gate, and residents can-not leave. This is a potential health and safety risk to residents in care.
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so that resident's personal rights are not violated.
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: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022


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Document Has Been Signed on 09/13/2022 02:48 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 09/13/2022 at 02:32 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYALTY ASSISTED LIVING
FACILITY NUMBER: 197609001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2022
Section Cited
CCR
87468.1(a)

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Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) to be accorded dignity in their... personal
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Administrators will remove the camera inside the newly built room in the facility.
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This requirement was not met, evidenced by, the newly installed bedroom has a camera inside the resident's room. This is a potential health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME:Cassandra Harris
LICENSING EVALUATOR NAME:Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022


LIC809 (FAS) - (06/04)
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