197603747-4-29-2022-31-AS-MCAA-CDXT5C-20220429142517

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603747
Report Date: 04/29/2022
Date Signed: 04/29/2022 02:25:59 PM

Document Has Been Signed on 04/29/2022 02:25 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 & CARE III		FACILITY NUMBER:	197603747
ADMINISTRATOR:	RADA KIGEL		FACILITY TYPE:	740
ADDRESS:	5809 MELVIN AVENUE		TELEPHONE:	(818) 609-7763
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	6	CENSUS: 5	DATE:	04/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Alexander Kigel, Gerrardo Centeno		TIME COMPLETED:	02:45 PM

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Licensing Program Analyst (LPA) Michael Cava arrived conducted a required Annual Inspection infection control vist at the facility. Upon arrival of the facility, LPA observed a large courtyard with patio furnishings for residents to sit outside. LPA met with the administrator, Alexander Kigel and caregiver Gerardo Centeno. LPA observed two (2) residents in the living room watching television, and the other three (3) residents in their rooms. Personnel summary was verified for criminal record/association; all staff were cleared. LPA observed one (1) staff on duty, and the administrator. Licensee Sophia Labendze was notified of the visit via telephone. The current census is five (5). Facility license and sketch, rights of resident council, grievance/complaint procedures, emergency disaster plan, resident bill of rights, personal rights, and neighborhood complaint procedures were visibly posted.

A physical plant tour of the facility inside and outside was conducted with caregiver Gerardo at around 11:15am. The following common areas: living, dining, kitchen, resident bedrooms, and bathrooms, was inspected to ensure the facility was in compliance with Title 22 Regulations:

Kitchen: Food service area had Licensing requirement of (7) day nonperishable, and (2) day perishable. Food was properly stored in a healthy manner. Frozen foods were properly wrapped and stored appropriately. There was a pantry, stocked with non-perishable. Food storage and preparation areas were clean and inaccessible to pests and toxins. Appliances were functional and clean. Chemicals, household supplies, and knives, and medication, was locked and stored in kitchen cabinets. Appliances had functional fixtures, and in good repair.

Living/dining/family/: All indoor passageways were free from obstruction; inside temperature was comfortable and measured at 77 degrees. All areas were clean and appropriately furnished for resident’s comfort.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

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 & CARE III	FACILITY NUMBER: 197603747
	VISIT DATE: 04/29/2022

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Bedrooms: The facility has (6) private bedrooms; with (1) room for staff. All bedrooms were properly properly furnished with appropriate bedding and linens. Rooms observed to have bedspread, sheets, pillowcase, mattress pad, and blankets, which all were in good repair. There were sufficient linens observed and available.

Bathrooms: There are (7) bathrooms; all were clean, with soap and towels, grab bars, and non-skid mats. Hot water measured in several resident’s bathrooms between 105 and 115 degrees Fahrenheit.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. There is a covered patio with appropriate seating for residents. Smoke alarms and carbon monoxide detectors are battery operated and were functional. Fire extinguishers in the hallway and kitchen were fully charged. The charge date was 07/26/21. First aid kit furnished fully equipped. All exit doors have alarms; all were operating correctly.

Pursuant to title 22, division 6, chapter 8, there was no immediate health and safety hazard observed at this time. The administrator was advised and a copy of this report given.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC809 (FAS) - (06/04)

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