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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603385
Report Date: 07/15/2024
Date Signed: 07/15/2024 01:55:52 PM


Document Has Been Signed on 07/15/2024 01:55 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:
07/15/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Zara Poghosyan - Director TIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual continuation - case management visit at the facility. LPA met with Zara Poghosyan and Tanya Quezada Administrator and explained the reason for the visit.

On 7/13/24 LPA Flores conducted an initial annual visit.
During today's visit LPA Flores reviewed the following CARE inspection tool domains: Infection Control, Staffing, Personnel Records/Staff Training, and Residents with Special Health Needs.

LPA reviewed 5 staff files. Administrator certificate was observed for Tanya Quezada #6056570740 expiration date: 7/8/24. Per staff documents were submitted to the department for renewal on 6/10/24. LPA reviewed Infection Control Plan was last reviewed on 5/11/22.

During the visit of 7/13/24 LPA observed resident #1(R1) on room #227 had half bed rails on the bed. R1 does not have a bed rail request on file.
During medication review conducted on 7/13/24 LPA Flores observed Resident #2(R2) had medication prescribed. However, the medication was not found during the review of medication. Med-Tech search for the medication but it was not found.

LPA interviewed 8 residents and 4 staff during this visit.

Deficiencies are noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Zara Poghosyan and Tanya Quezada 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: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
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 07/15/2024 01:55 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: 07/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87628(b)(2)
Diabetes
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (2) Ensuring that sufficient amounts of medicines, testing equipment, syringes, needles and other supplies are maintained and stored in the facility as specified in Section 87465(c).

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 1 out of 5 residents medication review, R2 does not have daily prescribed medication for allowable health condition which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/16/2024
Plan of Correction
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Administrator will contact pharmacy and obtain refill medication for R2 and will submit a picture of medication received at the facility and Administrator will provide training to medication staff and will submit a copy to the department by POC due date 7/16/24.
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: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/15/2024 01:55 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: 07/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in observation of half bed rails in room #227 in R1's bed, no written request on file for R1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2024
Plan of Correction
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Administrator will obtain physician's written request for half bed rails and submit a copy to the department by POC due date 7/15/24.
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: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
LIC809 (FAS) - (06/04)
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