198601566-4-3-2025-11-AS-YROR-DFDHGE-20250403061057

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601566
Report Date: 04/02/2025
Date Signed: 04/03/2025 06:11:08 AM

Document Has Been Signed on 04/03/2025 06:11 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	STUDIO ROYALE		FACILITY NUMBER:	198601566
ADMINISTRATOR/ DIRECTOR:	LEWIS,ERNEST D.		FACILITY TYPE:	740
ADDRESS:	3975 OVERLAND AVENUE		TELEPHONE:	(310) 836-5854
CITY:	CULVER CITY	STATE: CA	ZIP CODE:	90232
CAPACITY: 175		CENSUS: 94	DATE:	04/02/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Tamera Grant, Health and Wellness Director and William Boles, Jr. Executive Director		TIME VISIT/ INSPECTION COMPLETED:	04:20 PM

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	On 03/14/2024, Licensing Program Analyst (LPA) Yolanda Rosser conducted an unannounced annual required visit with the CARE Inspection Tool. LPA met with Health and Wellness Director, Tamera Grant and explained the purpose of today’s visit. Later LPA met with Executive Director, William Boles, JR. The facility is licensed to operate for one hundred and seventy-five (175) elderly residents ages 60 and above of which five (5) can be bedridden on the first floor and 74 non-ambulatory. The facility is approved for five (5) hospice. Currently there are 94 residents in facility. The facility is two stories with no memory care. There is a total of 37 resident rooms on the first floor and 57 rooms on the second floor. There is a parking area in the front and side of the facility. The lobby/receptionist area is located as you enter the building. There are two common bathrooms on each floor. The activity room is located on the first floor with plenty of activities including board games, cards, checkers, chess board games for the residents leisure. The dining room is located on the first floor with ample seating for clients and /or guests. The TV/Movie room are located on the first floor. The staff break room is located on the first floor. The library is located on the second floor with a computer accessible for residents. Located outside is patio area with canopies and tables with chairs all along the perimeter. The salon and physical therapy room is located on the second floor. LPA found the facility to be maintained adequately, art covering the walls, piano located in the foyer, music playing in the background. LPA and Health and Wellness Director toured the physical plant. There were no bodies of water or obstructions on the premises. Various rooms were inspected – where beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. Water temperature was measured and within Title 22 regulations between 108 degrees F and 110 degrees F. Cont'd on C page.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Yolanda Rosser
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: STUDIO ROYALE	FACILITY NUMBER: 198601566
	VISIT DATE: 04/02/2025

NARRATIVE

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A comfortable temperature was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly.

There is a walk in refrigerator and freezer fully stocked in the kitchen. Food deliveries are made to the facility every Tuesday and Thursday of every week. Multiple fire extinguishers were fully charged on each floor. Medication room is located on the second floor for the facility and was inspected. Laundry rooms exist on each floor.
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Fire drills are conducted monthly.

All mandated inspection control posters were posted.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Yolanda Rosser
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC809 (FAS) - (06/04)

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