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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603385
Report Date: 10/10/2022
Date Signed: 10/10/2022 11:19:55 AM

Document Has Been Signed on 10/10/2022 11:19 AM - 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, 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:
10/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Anna Rempel TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced visit for the purpose of conducting the required annual inspection focused on Infection Control Domain. LPA met with Administrator Anna Rempel, purpose of the visit was discussed.

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 Facility is a 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.

On todays visit LPA(s) followed the Infection control domain, toured the physical plant, reviewed eight (8) resident and five (5) staff files, and the medication records for five (5) residents. LPA conducted interviews of (4) staff and (4) residents. LPA observed required amount of perishable and non-perishable food items, fully stocked first aid kit, sufficient linen supplies, hygiene supplies, security cameras located in common areas, required postings were observed. Fire alarms, carbon monoxide detectors and the signalling systems are interconnected and notify the fire department when triggered. Fire panel last serviced observed to be serviced. Toxins and sharps locked and inaccessible to residents. Fire extinguishers fully charged. Facility has an approved mitigation plan on file. Physical plant clean and free of debris. Infection control domain completed.

No deficiencies are cited at the time of this visit. Exit interview was conducted and a copy of the report provided to Administrator Anna Rempel.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2022
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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