374604739-5-15-2024-08-AS-ADOO-D59V6A-20240514160915

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604739
Report Date: 05/14/2024
Date Signed: 05/15/2024 11:42:07 AM

Document Has Been Signed on 05/15/2024 11:42 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	ROYAL CARE INC		FACILITY NUMBER:	374604739
ADMINISTRATOR/ DIRECTOR:	NAZARIAN, ANNIE		FACILITY TYPE:	740
ADDRESS:	4440 LOWELL ST		TELEPHONE:	(818) 571-7701
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY: 6		CENSUS: 0	DATE:	05/14/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:45 PM
MET WITH:	Annie Nazarian Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

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Licensing Program Analyst (LPA) Amy Domingo conducted an announced Pre-Licensing and Comp III visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of California Code of Regulations and California Health & Safety Code and Comp III. LPA was greeted by, identified herself to, and explained the purpose of the visit to applicant Annie Nazarian.

The facility fire clearance was granted on 4/10/24 and reflects that the facility is approved for 1 ambulatory, 4 non ambulatory and 1 bedridden.

During today’s visit, LPA, accompanied by the applicant, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Client bedrooms allowed for easy passage and contained the required furnishings. Toilets and showers were in working order. The facility’s ambient internal temperature was 72 degrees F. Water temperature in a client bathroom was 110 F.

(Continue on LIC809C)

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ROYAL CARE INC	FACILITY NUMBER: 374604739
	VISIT DATE: 05/14/2024

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[Continued from LIC809]

The facility has enough linens, hygiene supplies, dining supplies, and perishable and non-perishable food for future client use. Refrigerator temperature was 34 F, and freezer temperature was -0 F. The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of medication and confidential client and staff records. No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Per the applicant, no firearms or ammunition are or will be stored at the facility.
Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. Fire extinguishers and first aid kits were present. Required licensing postings were observed in visible areas of the facility.

The items reviewed were compliant with Title 22, Division 6, Chapter 8 of California Code of Regulations and Health & Safety Code including Comp III. The applicant passed the pre-licensing inspection. LPA also provided the Component III Training during today’s visit. Annie Nazarian was advised that the facility’s application is pending management final review and approval. An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (3/22) were left with the Director, whose signature on this form confirms receipt of these documents.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

LIC809 (FAS) - (06/04)

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