197603385-7-22-2026-28-AS-BTAO-DW8VYV-20260722165145

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603385
Report Date: 07/22/2026
Date Signed: 07/22/2026 04:52:05 PM

Document Has Been Signed on 07/22/2026 04:52 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	COMMONWEALTH ROYALE GUEST HOME		FACILITY NUMBER:	197603385
ADMINISTRATOR/ DIRECTOR:	ZARA POGHOSYAN		FACILITY TYPE:	740
ADDRESS:	150 S. COMMONWEALTH AVE		TELEPHONE:	(213) 382-6381
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90004
CAPACITY: 106		CENSUS: 100	DATE:	07/22/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Zara Poghosyan, Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tao conducted an unannounced annual visit at the facility using the CARE inspection tool. Upon arrival, LPA met with the Administrator/Director of Operations, Zara Poghosyan. The reason for the visit was explained.

The facility is licensed to serve 106 residents and 14 non-ambulatory residents, ages 60 and above. Non-ambulatory residents may reside in rooms #101,102,103,104,105,106,107,122 on the first floor’s bedrooms only. Hospice Waiver approved 15 residents. Dementia Plan is in place. The facility has two floors. The first floor consists of 22 residents’ rooms, a lobby, two dining rooms, commercial kitchen, TV/ activity room, laundry room, staff break room, and common areas. The second floor consists of 31 resident rooms, business office, storages and medication room.

The following CARE tool domains were reviewed during this visit:

Infection Control: Sufficient PPE supplies and an Infection Control Plan maintained at the facility were observed and in compliance.

Physical Plant & Environment Safety: Physical plant tour was conducted. Residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The backyard, outdoor and passageways were free of obstruction and debris/hazards. Storage areas for cleaning solutions, toxins, knives, and hazardous items were kept in a locked cabinet and were inaccessible to residents. (-Continued on the LIC809-C)

Lisa Hicks
Bonnie Tao
	DATE: 07/22/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: COMMONWEALTH ROYALE GUEST HOME	FACILITY NUMBER: 197603385
	VISIT DATE: 07/22/2026

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Water temperature was tested and the temperatures were between 109.8 to 115 degrees F., which is in compliance with regulations. Smoke detectors and carbon monoxide detectors were tested on both floors and were operable. Fire extinguishers were observed and fully charged.

Operational Requirements and Disaster Preparedness: Facility has an activity area furnished for outdoor use. Fire drills were conducted monthly. The last fire drill was on 6/25/26. Call system was tested. The staff’s responding time was from 2 minutes to 5 minutes, which was in compliance.

Staffing and Personnel Records- Training: There appears to be sufficient staffing at all times in the facility. Staff files were reviewed and in compliance. Administrator certificate is current with the expiration date on 4/23/2027.

Resident Rights-Information and resident Records-Incident Reports: Facility provided telephone landline and internet for the residents. Resident rights posters and reporting posters were displayed within the facility.

Food Service: The kitchen was observed to be clean. Two (2) days of perishables and one-week (7) days of non-perishables food supply were observed.

Health Related Service: Medication was properly labeled, centrally stored, and in their original containers.

Incidental Medical & Dental and Emergency Intervention: Staff designated to administer medication have the proper training on file. Staff maintain a CPI Certificate in the case of use.

Exit:

Deficiencies were noted during this visit per California Code of Regulations, Title 22, Division 6. Exit interview was conducted with Administrator Zara. Copies of LIC 809s and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/22/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/22/2026 04:52 PM - It Cannot Be Edited

Created By: Bonnie Tao On 07/22/2026 at 04:26 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	The following medications were not documented, did not show as administered, did not have any explanations stated in resident’s medical records: Resident#1, JN, on 7/5/26, 7/8/26 & 7/9/26, 6pm Rx, Diclofenca Gel 1%, Atorvastatin Tab 40 MG, Docusate Sod 100 mg, Tamsulosin Cap 0.4mg, Xarelto Tab 20mg; on 7/8/26, evening Rx, Lidocaine Oin 5%. Resident#2 YS, on 7/5/26, Bedtime Rx, Amoxicillin Pill 125mg; on 7/5/26, 7/8/26 & 7/9/26, Bedtime Rx, Eliquis 5mg, Gabapentin 300 mg, Glipizide Tab 5mg, Atorvastatin 40mg; on 7/8/26 & 7/9/26, 5pm Rx, Metformin 500 MG. Resident#3 SE, on 7/8/26, evening/bedtime Rx, Alprozolam 0.5mg, Buprenorphin 2mg, Calcium 600mg, Gabapentin 300mg, Lactulose 10mg, Omeprazole 40mg, Ondansetron 8mg, Zanaflex 8mg, Buprenorphine 20mg, Famotidine 40mg, Pitavastatin 4mg, Trazodone 150mg. Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/23/2026
	Plan of Correction
1 2 3 4	Licensee agrees to provide 1) in-service training to the med staff, 2) a statement indicates how to prevent further medication discrepancies, 3) check all residents' medication that come in loose bottles. Provide proof of correction on the due date

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:

	Bonnie Tao
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/22/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026

LIC809 (FAS) - (06/04)

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