<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603385
Report Date: 01/19/2024
Date Signed: 01/19/2024 03:02:59 PM


Document Has Been Signed on 01/19/2024 03:02 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
GREATER LA AC/SC, 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: 88DATE:
01/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Anna RempelTIME COMPLETED:
03:00 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) Alma Gonzalez conducted a case management visit for the death of Resident 1 (R1) which occurred on 07/22/22.

LPA made an initial visit on 07/26/22. LPA reviewed death certificate and the death certificate indicates that the immediate cause of death for R1 was Sudden Cardiac Arrest and Atherosclerotic Cardiovascular Disease. A Biopsy was not performed. An autopsy was not performed. Other Significant Conditions contributing to death were listed as None. Place of Death: 186 S Commonwealth Avenue, Los Angeles 90004.

Based on the available information reviewed, LPA did not note any deficiencies in reference to R1's death.

Exit interview conducted and copy of report was provided to Assistant Administrator Anna Rempel.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1