197603747-5-27-2023-31-AS-TSMH-CS92EW-20230527172036

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603747
Report Date: 05/27/2023
Date Signed: 05/27/2023 05:20:40 PM

Document Has Been Signed on 05/27/2023 05:20 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: 6	DATE:	05/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:28 PM
MET WITH:	Sophia Labendze		TIME COMPLETED:	05:30 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 1:35 pm Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility. LPA was greeted by the administrator and disclosed purpose of visit. LPA conducted a tour of the physical plant at approximately 1:38 pm 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 guest lounge,living room, kitchen and dining 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 six (6) 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. The medications and first aid are stored in locked upper kitchen cabinets. Sharps stored and locked in kitchen drawer beneath the medication cabinet. Medications and sharps observed to be inaccessible to residents. Toxins stored under kitchen sink cabinet and observed to be locked and inaccessible to residents. There are two (2) fire extinguishers: one (1) in kitchen wall near refrigerator, one (1) in hallway next to bedroom # 6 attached to wall. Laundry room in guest bathroom near dining room. The appliances observed to be functional and in good repair.

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 & CARE III	FACILITY NUMBER: 197603747
	VISIT DATE: 05/27/2023

NARRATIVE

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(Cont from 809)
The facility has a total of seven (7) bedrooms; with one (1) designated for staff; and seven (7) bathrooms: six (6) private bathrooms for residents.
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 resident rooms.

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 six (6) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was between 112.9, 112.9, 110.0, 113.5, 108.3, and 110.6-degrees Fahrenheit.

There is a courtyard patio area in the front of facility. Patio furniture observed to be in good repair.
Backyard has the following: Large Gazebo with table with chairs and three (3) separate patio areas. Patio furniture observed to be in good repair.

Storage room in backyard for PPE/water/emergency supplies. No garage at facility
Smoke detectors/carbon monoxide detector were tested and operable at time of visit.
Exit door alarms operable at time of visit.

Facility grounds were free of hazards.

At approximately 02:35 pm, LPA reviewed files for the six (6) residing residents. Resident files review includes 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. Facility has dementia and bedridden plan.

There were no immediate health and safety hazard observed during the day of inspection.

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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