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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603385
Report Date: 02/04/2025
Date Signed: 02/04/2025 02:16:02 PM

Document Has Been Signed on 02/04/2025 02:16 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/
DIRECTOR:		MAYA MNOYANFACILITY TYPE:
740
ADDRESS:150 S. COMMONWEALTH AVETELEPHONE:
(213) 382-6381
CITY:LOS ANGELESSTATE: CAZIP CODE:
90004
CAPACITY: 99TOTAL ENROLLED CHILDREN: 0CENSUS: 92DATE:
02/04/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Anna Rempel (Administrator) and Zara Poghosyan (Director)TIME VISIT/
INSPECTION COMPLETED:
02:30 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) Elizabeth Irra conducted an initial complaint investigation visit and met with Ana Rempel (Administrator) and Zara Poghosyan (Director).

During this complaint visit, it was discovered that R-1’s records were incomplete. LPA discovered multiple staff initials missing on R-1’s Medication Administration Record (MAR) for the January 2025 log. The MAR was missing initials for the following medications: Triamcinolone, Aripiprazole, Lorazapam/Avitan, Fluocinonide, Ammonium Lactate, Citalopram, Lisinopril, Atorvastatin, Metformin HCI, Eliquis, Carvedilol and Clotrimazole.

Deficiency is being cited according to California Code of Regulations, Title 22. Refer to LIC 809D.

Exit interview, appeal rights and a copy of this report was provided to Anna Rempel (Administrator).

Tony VasalloTELEPHONE: (323) 981-3977
Elizabeth IrraTELEPHONE: (323) 981-3979
DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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 2
Document Has Been Signed on 02/04/2025 02:16 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: 02/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2025
Section Cited
CCR
87506(a)

1
2
3
4
5
6
7
Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This standard is not met as evidence by:
1
2
3
4
5
6
7
Administrator to provide in-service training to staff pertaining to medication administration documentation and provide proof of training to LPA Irra by POC due date.
8
9
10
11
12
13
14
R-1’s records were incomplete. LPA discovered multiple staff initials missing on R-1’s Medication Administration Record (MAR) for the January 2025 log.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tony VasalloTELEPHONE: (323) 981-3977
Elizabeth IrraTELEPHONE: (323) 981-3979

DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025

LIC809 (FAS) - (06/04)
Page: 2 of 2