<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610363
Report Date: 12/09/2024
Date Signed: 12/09/2024 11:00:29 AM

Document Has Been Signed on 12/09/2024 11:00 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:AAA ROYAL SENIOR LIVING FACILITYFACILITY NUMBER:
197610363
ADMINISTRATOR/
DIRECTOR:		KRISTINA ADMAYANFACILITY TYPE:
740
ADDRESS:6214 BECKFORD AVETELEPHONE:
(818) 609-0117
CITY:TARZANASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 5DATE:
12/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Kristina Admayan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 31-AS-20240913135055). Upon arrival, LPA met with administrator Kristina Admayan. The purpose of this visit is to issue citation for a deficiency observed during the complaint investigation.

On 09/17/2024, LPA Rahimi conducted an initial 10-day visit, at which time copies of pertinent documents from Resident #1 (R1) facility file were obtained and reviewed. Review of documents and interview with the Administrator confirmed that although on 09/06/24, the facility staff observed changes in R1's condition, Administrator failed to do proper reassessment/reappraisal for R1's changes.


Pursuant to Title 22, California Code of Regulations, a deficiency will be cited (refer to LIC 9099-D

Exit interview conducted, appeal rights discussed, and a copy of this report has been signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/09/2024 11:00 AM - It Cannot Be Edited


Created By: Huma Rahimi On 12/09/2024 at 10:42 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: AAA ROYAL SENIOR LIVING FACILITY
FACILITY NUMBER: 197610363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2024
Section Cited
CCR
87463(a)

1
2
3
4
5
6
7
87463 Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Licensee agreed to develop a plan to address reappraisals of residents as frequently as necessary and provide in-service training to all staff regarding the Section 87463. Proof of training should be submitted to CCLD by POC date.
8
9
10
11
12
13
14
Based on record review and interview during investigation, the licensee did not comply with the section cited above by not completing a resident appraisal due to changes in R1’s medical condition, which poses/posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2