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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191502216
Report Date: 10/14/2025
Date Signed: 10/14/2025 01:40:53 PM

Document Has Been Signed on 10/14/2025 01:40 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ROYAL OAKSFACILITY NUMBER:
191502216
ADMINISTRATOR/
DIRECTOR:		ANDREW M SMITHFACILITY TYPE:
741
ADDRESS:1763 ROYAL OAKS DRIVETELEPHONE:
(626) 359-9371
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY: 250CENSUS: 208DATE:
10/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Eusebio Tienda, Director of WellnessTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted the required unannounced annual inspection. LPA met with Director of Wellness, Eusebio Tienda and explained the purpose for the visit. The facility is licensed to serve a capacity of two hundred (250) residents ages 60 and above, with a maximum of (25) Non-Ambulatory in the Bradbury Building. There is an approved Hospice Waiver on file for four (4) residents. The facility also has an approved Dementia Care plan as part of their operation. There are currently 24 residents in Assisted Living and 184 residents in Independent Living.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has an Infection Control Plan in place which was last updated on 08/05/2025. Emergency and disaster plan was completed and up to date.

Operational Requirements: The facility has an approved fire clearance and facility maintains the required liability insurance in place. There is an approved Dementia Care plan in place. Last fire drill was last conducted on 09/22/2025.

Physical Plant & Environment Safety: This is a Continuing Care Retirement Community (CCRC) which includes separate buildings throughout the premises; Independent Living, Assisted Living and Skilled Nursing. The Assisted Living residents reside on the second floor of the Bradbury Oaks building and other residents are at the Independent Living care section. The wander guard system is used in the Bradbury Oaks building (second floor) for residents diagnosed with dementia or wandering behaviors, this was tested during visit and was in order.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ROYAL OAKS
FACILITY NUMBER: 191502216
VISIT DATE: 10/14/2025
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Physical Plant & Environment Safety [Cont.]: LPA inspected six (6) residents' rooms and each resident bedroom has the required furniture such as the bed, bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. The bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, skid matt/strips and shower chair. The hot water temperature was tested throughout the facilities resident’s six (6) private bathrooms and measured between 114.9 degrees F to 116.6 degrees F which are within the required range of 105-120 degrees. Cleaning supplies are secure, locked and inaccessible to residents. Sharps are secure, locked and inaccessible to residents. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged and last inspected on 04/14/2025. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. There are multiple shaded patio/garden areas for residents.

Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency.

Personnel Records-Training: LPA reviewed five (5) staff files that included personnel record, criminal record clearance, health screening, TB clearance, Employee Rights, valid First-Aid/CPR/AED training, and staff training. Executive Director/Administrator, Andrew Smith certificate expires on 2/11/2027.

Residents Rights-Information: Residents are provided with telephone and internet access at the facility. The facility has the following posters posted throughout common areas: Residents Rights, Complaint Poster, and Ombudsman.

Planned Activities: Facility provides scheduled activities with a monthly calendar and the required full-time staff that conduct and evaluate planned activities. There is sufficient space both indoor and outdoor for activities.

Food Service: Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables, along with the emergency food supply.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ROYAL OAKS
FACILITY NUMBER: 191502216
VISIT DATE: 10/14/2025
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Incidental Medical & Dental: Medications were reviewed for five (5) residents to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are centrally stored and in their original containers. Medications are administered as prescribed by the Physician. Medications are bubbled packed and in bottles. The first Aid kit was observed and has all required items.

Resident Records-Incident Reports: LPA reviewed five (5) resident files which included Face Sheet, Pre-admission Appraisal/Assessment, Service Plan, Admission Agreements, Physician's Report, Ambulatory Status, TB Clearance, and Personal Rights. There were no issues observed.

Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least two (2) relocation sites. LPA observed the Evacuation chairs mounted near the stairway. The last drill was conducted on 9/22/25 in the assisted living (Bradbury Building).

Residents with Special Health Needs: Per Director of Wellness, there are one (1) residents under hospice care, (0) residents receiving home health services and two (2) residents using oxygen have "No smoking in use" signs posted. Dr.’s Order for one (1) resident’s Hospital Bed is in file. Facility has hospice care plan in place.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during today’s visit. Exit interview was held and a copy of the report was provided to Director of Wellness, Eusebio Tienda.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC809 (FAS) - (06/04)
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