197603385-9-7-2023-28-AS-AGOZ-CVG37J-20230907180002

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603385
Report Date: 09/07/2023
Date Signed: 09/07/2023 06:00:10 PM

Document Has Been Signed on 09/07/2023 06:00 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 HOME		FACILITY NUMBER:	197603385
ADMINISTRATOR:	KITT, GARY		FACILITY TYPE:	740
ADDRESS:	150 S. COMMONWEALTH AVE		TELEPHONE:	(213) 382-6381
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90004
CAPACITY:	99	CENSUS: 85	DATE:	09/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Anna Rempel		TIME COMPLETED:	03:30 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 the required annual inspection. LPA met with Assistant Administrator Anna Rempel and discussed the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility is using appropriate hand hygiene and wearing gloves while assisting residents. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for (85) ambulatory and (14) non-ambulatory residents age 60 and above. Non-ambulatory residents in first floor bedrooms only. Hospice Waiver approved for 15 residents. Last Fire Drill was conducted 03/16/23. Staff are adhering to operational requirements. Staffing: There is sufficient staffing at the facility. Administrator Certificate for Anna Rempel on file has an expiration date of 06/11/24. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator and Staff 1 (S1) - Staff 3 (S3). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights. Staff have on-going training. (See LIC809C for the continuation of this report)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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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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
	VISIT DATE: 09/07/2023

NARRATIVE

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Resident Rights-Information: RCFE complaint poster and Personal rights were observed posted in the facility as well as LTCO poster. Per Facility Administrator, facility provides wi-fi services for facility residents.

Resident Records-Incident Reports: LPA reviewed Resident files for R1 8. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Functional Capabilities, Appraisal/Needs and Services Plan, Resident Rights were observed.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place.

Physical Plant & Environment Safety: LPA conducted a tour of the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The physical plant tour was conducted with the assistance of Assistant Administrator Anna Rempel. The physical plant consists of a two story building with 52 rooms with bathrooms in each room, offices, lobby, TV Room/ Activity Room, 2 dining rooms, kitchen, storage, laundry and outside patio. Resident rooms were randomly chosen for inspection and LPA observed that resident bedrooms have the required furniture, bed linens, sufficient lighting and closet/drawer space to accommodate each resident comfortably. Private resident bathrooms in rooms were inspected. Restrooms were clean, toilets and water faucets worked properly and were properly supplied, have functional fixtures and have secure grab bars, showers were free of mold/ mildew and non-skid mats or strips were properly in place. Hygiene supplies are provided. Water temperature was measured in a total of 8 resident rooms and temperatures ranged from 111 to 117 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately available.

Planned Activities: Calendars and supplies for activities were observed.

Refer to LIC 809C for the continuation of this report

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC809 (FAS) - (06/04)

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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: COMMONWEALTH ROYALE GUEST HOME	FACILITY NUMBER: 197603385
	VISIT DATE: 09/07/2023

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Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. Additional food supply was also observed. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining room has adequate seating. Posted menu observed.

Health Related Services/Incidental Medical Services: The medications are centrally stored in the office/ medication room and in bubble packs and/or original containers. LPA reviewed medication for R1-8. The facility uses the Medication Administration Records (MARs) to document medications given to residents. Medications are administered as prescribed by the Physician. The facility provides incidental medical services.

Per Title 22 Regulations, there were no deficiencies observed during visit.

Exit interview and a copy of this report was provided to Assistant Administrator Anna Rempel.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC809 (FAS) - (06/04)

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