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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603747
Report Date: 09/21/2021
Date Signed: 09/21/2021 11:54:10 AM

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 & CARE IIIFACILITY NUMBER:
197603747
ADMINISTRATOR:RADA KIGELFACILITY TYPE:
740
ADDRESS:5809 MELVIN AVENUETELEPHONE:
(818) 609-7763
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:6CENSUS: 6DATE:
09/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Rada SigalTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Calvin Tsui and Licensing Program Manager (LPM) Eva Miller conducted a Case Management visit in reference to deficiencies observed during the investigation of a complaint (Control #31-AS-20210903113520).

On 9/9/21, LPA Calvin Tsui & LPA Yelena Avetisyan observed that the facility did not have a documented Absentee Notification Plan as required.

On 9/9/21, the LPA's observed that the exterior door to R-1's bedroom (#5) was blockaded with the use of furniture placed outside the door to prevent R-1 from exiting. This deficiency violates the Fire Clearance by blocking an exit and is a Zero Tolerance Deficiency.

Citations issued, Civil Penalties Assessed, Appeal Rights provided and an exit interview conducted.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Calvin TsuiTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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
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 & CARE III
FACILITY NUMBER: 197603747
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2021
Section Cited

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Care of Persons with Dementia. The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2)The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.
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This requirement was not met as evidenced by observations by LPA's that the exterior door to the bedroom of R-1 was blockaded without fire clearance approval to prevent exit resulting in an immediate threat to the health & safety of residents in care. Zerio Tollerance.
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Type B
09/28/2021
Section Cited

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Absentee notification plan for missing residents. Every RCFE shall,develop and comply with an absentee notification plan as part of the written record of the care the resident will receive in the facility, as described in Section 1569.80. This requirement was not met as evidenced by:
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Based on Observations of LPA's during records review there was no absentee notification plan in place for Resident #1 resulting in a potential risk to the health and safeth of resident(s) in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Calvin TsuiTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2021
LIC809 (FAS) - (06/04)
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