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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603385
Report Date: 07/13/2024
Date Signed: 07/13/2024 02:18:38 PM


Document Has Been Signed on 07/13/2024 02:18 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:ANNA REMPELFACILITY TYPE:
740
ADDRESS:150 S. COMMONWEALTH AVETELEPHONE:
(213) 382-6381
CITY:LOS ANGELESSTATE: CAZIP CODE:
90004
CAPACITY:99CENSUS: 83DATE:
07/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Zara Pghosyan - Director TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Zara Pghosyan and explained the reason for the visit.

The facility is licensed to served 85 ambulatory and 14 non-ambulatory residents ages 60 and above. Non-ambulatory residents in first floor only. Hospice waiver approved for 15 residents. The facility is located in a residential area and consist of a large two story building. First floor has a commercial kitchen, two dining rooms, a courtyard, a lobby, office space, resident rooms, and a front patio. Second floor has resident rooms, medication room. Storage spaces are throughout the facility.

LPA conducted a tour of the facility with Zara Pghosyan and observed the following:
Facility is in good repair indoor and outdoor. Commercial kitchen is clean, and food supplies were stored sufficient for at least two days of perishables and 7 days of non-perishables. Common areas are clean and in good repair. All the required postage was observed throughout the first floor. LPA observed 8 randomly chosen resident rooms which have sufficient lighting, the required furniture, and bedding supplies. Water temperature was tested in each bathroom and tested between 97.7 - 117.2 degrees F. which is not within the required 105-120 degrees F. Bathrooms were observed to have the required grab bars and skid strips on showers. Call system was tested in 4 rooms and receptionist responded to each call immediately. No large bodies of water were observed. Facility has a fire sprinkler system throughout. Smoke/Carbon monoxide detectors were tested in each room and are in working condition.
LPA reviewed medication and files for 5 residents and Emergency Disaster Plan LIC 610E (10/03) dated 9/19/23. Last emergency drill was conducted 5/26/24.
During this visit LPA conducted the following CARE tool domains:Operational Requirements, Physical Plant/Environmental Safety, Resident Rights/Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records/Incident Reports, Disaster Preparedness. Due to time LPA will return at a later time to finish the remaining domains.
Deficiency was noted on LIC 809D, and technical violations were noted.
Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2024
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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Document Has Been Signed on 07/13/2024 02:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 197603385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 5 residents with PRN medications do not have records of PRN medication taken and the medication has been distributed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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Administrator will ensure that the PRN medication list is created and training will be provided to med-techs to ensure that the records are maintained for the residents with PRN medications copies of training and sheets will be provided to the department by POC due date 7/19/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2024
LIC809 (FAS) - (06/04)
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