191502216-10-24-2023-28-AS-BTAO-CWWVFQ-20231024162417

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191502216
Report Date: 10/24/2023
Date Signed: 10/24/2023 04:24:25 PM

Document Has Been Signed on 10/24/2023 04:24 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ROYAL OAKS		FACILITY NUMBER:	191502216
ADMINISTRATOR:	ANDREW M SMITH		FACILITY TYPE:	741
ADDRESS:	1763 ROYAL OAKS DRIVE		TELEPHONE:	(626) 359-9371
CITY:	DUARTE	STATE: CA	ZIP CODE:	91010
CAPACITY:	250	CENSUS: 165	DATE:	10/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:39 AM
MET WITH:	Tony Agoncillo, Health Services Adm		TIME COMPLETED:	04:30 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	Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Health Services Administrator, Tony Agoncillo and Nurse director, Eusebio (Sev) Tienda, who assisted with the visit. LPA discussed the purpose of today's visit with administrator. During the visit, LPA conducted staff/resident interviews, used CARE inspection tool, toured the facility, reviewed food supply, reviewed medications, and reviewed staff/residents records. The facility is licensed to serve two hundred fifty (250) residents ages 60 and above. A maximum of 25 Non-Ambulatory residents in the Bradbury Oaks building. Facility has approved Hospice Waiver for four (4) residents. Currently, there is one (1) resident on hospice. Approved Dementia Care plan is in place. This is a Continuing Care Retirement Community (CCRC) which includes three separate levels of care; Independent Living, Assisted Living and Skilled Nursing. The Assisted Living residents reside on the second floor of the Bradbury Oaks building which had 28 residents. Other residents are living at the Independent Living care section. The wander guard system is used in the Bradbury Oaks building (second floor) for residents diagnosed with dementia, who have wandering behaviors. Medications were centrally stored, locked and inaccessible to residents in care. All the rooms are furnished with appropriate furniture for residents’ comfort. The bathrooms are furnished with grab bars and nonskid surfaces. Common areas are observed for the ability to safely serve the needs of the residents. (-continued in LIC 809 C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ROYAL OAKS	FACILITY NUMBER: 191502216
	VISIT DATE: 10/24/2023

NARRATIVE

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Hot water temperature is in a range of 107.5 to 118.4 degrees Fahrenheit which was within Title 22 Regulation guidelines. A comfortable temperature of 73 degrees Fahrenheit maintained throughout the entire facility.

All exit doors are equipped with "wander guard system." Signal system is operational. Last emergency drill is conducted on 9/20/23 and fire drill on 7/18/23.

Sufficient supply of perishable and non-perishable foods is observed. Kitchen has required equipment and is in compliance. Smoke detectors and carbon monoxide detectors are monitored by a fire prevention company. All mandated documents and signages are posted in common areas.

No deficiency was cited per California Code of Regulations, Title 22. An exit interview was conducted and this report was discussed with Nurse Director, Eusebio P (Sev) Tienda.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

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