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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609001
Report Date: 11/13/2024
Date Signed: 11/14/2024 12:55:26 AM

Document Has Been Signed on 11/14/2024 12:55 AM - 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ROYALTY ASSISTED LIVINGFACILITY NUMBER:
197609001
ADMINISTRATOR/
DIRECTOR:		AVETIAN, LIDUSHFACILITY TYPE:
740
ADDRESS:10940 STRATHERN STREETTELEPHONE:
(818) 436-9088
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 10CENSUS: 9DATE:
11/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:09 PM
MET WITH:Estela Avetyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Leizl de la Cerra conducted an unannounced Required 1 year visit to this facility. LPA was greeted by staff. Administrator, Estela Avetyan was notified by phone and arrived thereafter.

A tour of the physical plant was conducted from 2:00PM to 3:00PM with staff member, Kara who escorted LPA throughout the facility. The facility has seven (7) private bedrooms, in which five (5) bedrooms are designated for residents, one (1) room is for staff use, one (1) empty room, with no clients and two (2) full bathrooms.

Smoke detectors and carbon monoxide detectors were tested and functioned properly during time of visit. LPA observed three (3) fire extinguishers that appeared to be fully charged. Last disaster drill was conducted on Sept. 19, 2024.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects and cleaning supplies are stored in a locked cabinet. . Medications are placed in a locked cabinet in the kitchen area.

Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

Bathrooms: LPA observed all bathrooms appear to be clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. The hot water was measured within requirement of title 22 regulations.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROYALTY ASSISTED LIVING
FACILITY NUMBER: 197609001
VISIT DATE: 11/13/2024
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Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality. All areas were clean, sanitary and in good repair.

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises.

LPA conducted a file review for five (5) residents between 3:15PM to 4:30PM. While reviewing the records LPA observed various forms in residents files that were incomplete and/or missing required information.

Due to time constraints, LPA was unable to complete the annual visit at this time. LPA did not finish reviewing staff records or medication documentation at the time of this visit.
A follow-up visit will be conducted at a later date to complete the annual inspection.

Deficiency observed (refer to LIC809-D). Exit Interview Conducted. Appeal Rights and a copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/14/2024 12:55 AM - It Cannot Be Edited


Created By: Leizl De La Cerra On 11/13/2024 at 05:30 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: 11/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 residents appraisal records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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Licensee will conduct a record review and identify resident files with incomplete or missing documentation. Licensee will send to LPA via email the LIC625 for those residents missing documentation by POC date 11/27/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Naira Margaryan
LICENSING EVALUATOR NAME:Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2024


LIC809 (FAS) - (06/04)
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