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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603385
Report Date: 08/30/2021
Date Signed: 08/30/2021 03:25:13 PM

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:COMMONWEALTH ROYALE GUEST HOMEFACILITY NUMBER:
197603385
ADMINISTRATOR:KITT, GARYFACILITY TYPE:
740
ADDRESS:150 S. COMMONWEALTH AVETELEPHONE:
(213) 382-6381
CITY:LOS ANGELESSTATE: CAZIP CODE:
90004
CAPACITY:99CENSUS: 92DATE:
08/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Gary KittTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Gary Kitt and explained the purpose of today's visit.

This is an RCFE with a capacity of 99. The facility is licensed to serve 85 ambulatory residents and 14 non-ambulatory residents. All non-ambulatory residents on the first floor only. The facility has a hospice waiver approved for 15 residents. The following was inspected and toured: entire two story building with 52 rooms with bathrooms in each room, office, lobby, TV Room/ Activity Room, 2 dining rooms, kitchen, storage, laundry and outside patio.

The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, and in all common rooms and hallways.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Residents are able to use their private accommodations as isolation rooms if they have private rooms and if residents have shared rooms there are designated rooms to be used as isolation rooms if a COVID-19 positive case should arise.
  • 30 day supply of medication reviewed for (9) residents (Resident #1 through Resident #8)
  • Facility has an adequate amount of PPE and facility has enough PPE for 90 days.
  • Residents were socially distanced according to local public health guidelines.
  • Residents wearing masks.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed (including paper goods, utensils etc).
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
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: COMMONWEALTH ROYALE GUEST HOME
FACILITY NUMBER: 197603385
VISIT DATE: 08/30/2021
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According to the California Code of Regulations, LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Administrator Gary Kitt and copy of report provided.

SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
LIC809 (FAS) - (06/04)
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