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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610363
Report Date: 02/04/2025
Date Signed: 02/04/2025 04:46:45 PM

Document Has Been Signed on 02/04/2025 04:46 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 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: 4DATE:
02/04/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:51 PM
MET WITH:Kristina Admayan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Huma Rahimi conducted unannounced visit to this facility in conjunction with a complaint control # 31-AS-20250131102508. LPA met with the Administrator Kristina Admayan who granted access to facility. LPA explained the reason for the visit.
During the visit LPA requested to review the medication for Resident #2 (R2) who seemed drowsy. Review of medication revealed that a bubble pack of thirty (30) tablets of Januvia 25MG (Type 2 Diabetes) which was filled on 12/30/2024 was supposed to be given to R2 one tablet daily. However, LPA observed that there are eight (8) extra tablets in the bubble pack. Additionally, LPA observed a full bubble pack of the same medication which was filled on 01/27/2025. LPA asked the Administrator and the staff for explaining and both stated that R2 refuses taking medication. LPA was informed that R2's POA advised the Administrator not to provide medication if R2 refuses. Administrator informed LPA that they did not inform R2's Physician nor submitted an incident report to Community Care Licensing Department (CCLD).

Deficiencies cited.
Appeal rights given. Exit interview conducted.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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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Document Has Been Signed on 02/04/2025 04:46 PM - It Cannot Be Edited


Created By: Huma Rahimi On 02/04/2025 at 04:30 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: AAA ROYAL SENIOR LIVING FACILITY
FACILITY NUMBER: 197610363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2025
Section Cited
CCR
87465(c)(2)

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87465- Incidental Medical and Dental Care:
c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions.

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Administrator agreed to schedule vendorized training for all staff by 02/06/2025 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion. Administrator also agreed to notify doctor and submit LIC 624 to CCL regarding the incident.
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Based on (observation) (interview) (record review)], the licensee did not comply with the section cited above in
not assuring that R2's prescribed medications were given as prescribed, which poses an immediate health, safety or personal rights risk to persons 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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/04/2025 04:46 PM - It Cannot Be Edited


Created By: Huma Rahimi On 02/04/2025 at 04:34 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: AAA ROYAL SENIOR LIVING FACILITY
FACILITY NUMBER: 197610363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/11/2025
Section Cited
CCR
87211(a)(1)A,B,&D

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Requirements: (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)...
This requirement is not met as evidenced by:
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Administrator agreed to submit a Special Incident Report (SIR) for R2's medication refusal. Administrator will have to submit a statement of understanding about the above section and reporting requirements.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in not submitting an incident for R2's medication refusal which poses/posed a potential health, safety or personal rights risk to persons 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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


LIC809 (FAS) - (06/04)
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