197603746-5-27-2023-31-AS-TSMH-CS8RYQ-20230527132644

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603746
Report Date: 05/27/2023
Date Signed: 05/27/2023 01:26:48 PM

Document Has Been Signed on 05/27/2023 01:26 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ROYAL GARDEN BOARD AND CARE II		FACILITY NUMBER:	197603746
ADMINISTRATOR:	RADA KIGEL		FACILITY TYPE:	740
ADDRESS:	5909 MELVIN AVENUE		TELEPHONE:	(818) 609-7753
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	6	CENSUS: 3	DATE:	05/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	07:27 AM
MET WITH:	Sophia Labendze		TIME COMPLETED:	01:30 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	At 7:27 am Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility. LPA was greeted by facility staff and disclosed the purpose of the visit. The administrator was contacted, and the Licensee and Administrator arrived later. LPA conducted a tour of the physical plant at approximately 8:00 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Common areas were observed for the ability to safely serve the needs residents. These included the kitchen, living room/dining combination, family room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately with adequate seating for residents. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the three (3) residents currently residing there. Two (2) days of perishable food and seven (7) days non-perishable food observed. The freezer is stocked with meats and frozen vegetables. Canned foods stored in hallway pantry. Additional/emergency food water in backyard shed. Sharps stored and locked in kitchen drawer. The medications and first aid are stored in locked upper kitchen cabinets. Sharps and medications observed to be inaccessible to residents. Toxins stored under kitchen sink in locked in cabinet and observed to locked and inaccessible to residents. There are three (3) fire extinguishers: one (1) in kitchen attached to side of counter, one (1) in hallway next to bedroom #4 attached to wall and one (1) near bedroom #2 attached to wall in hallway. Laundry room in backyard alcove. The appliances observed to be functional and in good repair. (Cont to 809C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYAL GARDEN BOARD AND CARE II	FACILITY NUMBER: 197603746
	VISIT DATE: 05/27/2023

NARRATIVE

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(Cont from 809)

The facility has a total of five (5) bedrooms; with one (1) designated for staff, and (3.5) bathrooms. The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens in each room.

Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured for the three (3) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature for the bathrooms measured:117.3, 120.2 and 124.7 degrees Fahrenheit.

Backyard has the following: Large Gazebo with table with chairs. Patio furniture observed to be in good repair. Pool on premises observed to be enclosed by a fence, locked and inaccessible to residents in care.

No garage at facility

Smoke detectors/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards. There were no immediate health and safety hazard observed during the day of inspection.

At approximately 09:50 am, LPA reviewed files for the three (3) residing residents. Resident files review include but not limited to: admissions agreement, physicians’ assessment, appraisals, consent and personal right forms. Staff files reviewed for four (4) staff. Staff files had medication trainings, dementia training's, certificate including current First aid/AED/CPR certificates. Administrator has current administrators certificate. Facility has dementia and bedridden plan.

Exit Interview Conducted / A Copy of the Report Issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2023

LIC809 (FAS) - (06/04)

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