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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604739
Report Date: 09/09/2024
Date Signed: 09/10/2024 07:55:56 AM

Document Has Been Signed on 09/10/2024 07:55 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ROYAL CARE INCFACILITY NUMBER:
374604739
ADMINISTRATOR/
DIRECTOR:		NAZARIAN, ANNIEFACILITY TYPE:
740
ADDRESS:4440 LOWELL STTELEPHONE:
(818) 571-7701
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY: 6CENSUS: 1DATE:
09/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Caregiver Remedio De RosarioTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management Visit. LPA was allowed entry, identified herself, and discussed the purpose of the visit with Caregiver Remedio De Rosario. All staff present had current criminal record clearance. LPA Strong spoke with Administrator Annie Nazarian via telephone.

Today's visit is in response to the self-reported incident which occurred on 9/1/2024 regarding an AWOL of Resident 1 (R1 - see LIC811 Confidential Names List).

According to the report submitted by the facility on 9/3/2024 R1 left facility unassisted on Sunday 9/1/24 after having an emotional outburst. Interview with staff present on the date of the incident revealed that emergency personnel were contacted within minutes of R1 leaving the home.

LPA conducted a wellness check at the facility by touring the facility, observing a resident in care that appeared appropriate for the facility, interviewed staff, and collected resident records.

Based on facility records and interviews, staff followed absentee notification plan as required. LPA Strong also provided regulation consultation via telephone.

An exit interview was conducted with the Caregiver Remedio De Rosario. A copy of this report and appeal rights (LIC9056 03/22), were provided via hardcopy at the conclusion of the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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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