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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603385
Report Date: 07/26/2022
Date Signed: 07/26/2022 05:50:16 PM


Document Has Been Signed on 07/26/2022 05:50 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
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: 90DATE:
07/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Anna RempelTIME COMPLETED:
05:30 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) Alma Gonzalez conducted a case management visit to follow-up on the death of Resident 1 (R1). LPA met with Assistant Administrator Anna Rempel and explained the reason for the visit. LPA interviewed Assistant Administrator Anna Rempel. According to the incident report dated 7/22/22, R1 passed away on 7/22/22. Per Assistant Administrator the suspected cause of death was stated by paramedics as natural causes. R1 was seen outside of the facility by a staff member who reported to Assistant Administrator that R1 was seen unresponsive down the street away from the facility and Assistant Administrator Rempel immediately called 911. Assistant Administrator contacted all applicable agencies to report the incident/ death. Police Department did not leave a police report number.

During today's visit, LPA interviewed Assistant Administrator Rempel and reviewed R1's file. LPA requested copies of the following documents:

· Physician's Report For Residential Care Facilities For The Elderly (RCFE) dated 2/17/21
· Appraisal/ Needs and Services Plan
· Medication Sheet dated for July 2022
· Identification and Emergency Information
· Preplacement Appraisal Information
· Resident Appraisal

Assistant Administrator was asked to provide a copy of R1's death certificate when it becomes available.


Exit interview conducted and copy of Report was provided to Assistant Administrator Anna Rempel.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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