197602857-5-24-2023-29-AS-EPEI-CS5VQZ-20230524163909

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602857
Report Date: 05/24/2023
Date Signed: 05/24/2023 04:39:47 PM

Document Has Been Signed on 05/24/2023 04:39 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ROYAL GARDEN		FACILITY NUMBER:	197602857
ADMINISTRATOR:	KIGEL, ALEKSANDR		FACILITY TYPE:	740
ADDRESS:	6159 ATOLL AVE		TELEPHONE:	(818) 909-0210
CITY:	VALLEY GLEN	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 4	DATE:	05/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:48 AM
MET WITH:	Sophia Labendze, Licensee		TIME COMPLETED:	04:50 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) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 9:48 a.m., the LPA met with staff and explained the reason for it visit. At 10:20 a.m., the Licensee arrived at the facility. At 10:55 a.m., the LPA, along with the Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 11:03 a.m., hot water measured at 105.1-degree Fahrenheit. Medications and first aid kit are located in a locked kitchen cabinet. BEDROOMS: The facility is a single-story residence and consists of six (6) bedrooms and four (4) bathrooms. There is an additional room for staff use. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 11:28 a.m., hot water measured between 105.4 and 110.9-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. OUTDOOR SPACE: At 11:13 a.m., the LPA observed the back patio which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. The garage is detached and remains inaccessible to residents. There is a washer and dryer in the garage. There are no bodies of water on the premises. Continued on LIC-809.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYAL GARDEN	FACILITY NUMBER: 197602857
	VISIT DATE: 05/24/2023

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COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 07/31/2022. At 11:33 a.m., fire alarms/carbon monoxide detectors were tested and functioned properly.

Between 11:16 a.m. and 11:42 a.m., the LPA conducted interviews with four (4) out of four (4) residents and three (3) staff.

RECORD REVIEWS: Between 12:57 p.m. and 2:00 p.m., the LPA conducted a file review for all residents and staff regularly scheduled and observed the following: Staff have current first aid and training documentation showing required training completed. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All files were in order.

Between 2:06 p.m. and 3:18 p.m., the LPA conducted a review of medication and medication documentation with the Licensee for four (4) out of four (4) residents and observed that all medications were properly documented and assisted with as prescribed.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC809 (FAS) - (06/04)

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