197606562-7-15-2024-31-AS-HRAI-D782WH-20240715174534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606562
Report Date: 07/15/2024
Date Signed: 07/15/2024 05:47:33 PM

Document Has Been Signed on 07/15/2024 05:47 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ROYALTY GUEST HOME, INC.		FACILITY NUMBER:	197606562
ADMINISTRATOR:	ELENA ANGUSTIA		FACILITY TYPE:	740
ADDRESS:	20609 BRYANT STREET		TELEPHONE:	(818) 727-1741
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91306
CAPACITY:	6	CENSUS: 2	DATE:	07/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Elena Angustia, Administrator		TIME COMPLETED:	06:20 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 9:50 AM Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with the Administrator, Elena Angustia and explained the reason for the visit. At 10:20 AM, physical tour was conducted with the Administrator and LPA observed the following: Kitchen: At approximately, 10:21 AM LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. LPA observed a scissor in one of the drawers in the kitchen accessible to residents in care. LPA also observed roaches crawling on the kitchen food, utensils, walls, and inside the fridge. LPA also observed a think pile of grease/dust in the kitchen. A spray of Ant & Roach (Raid Brand) was also observed and accessible to residents in care. Other knives were observed locked. All trash cans were observed without a tight-fitting lids. Medications: At approximately, 10:22 AM LPA observed medications are centrally stored and locked in a kitchen cabinet. LPA observed over the counter medication for severe congestion & cough in Bedroom # five (5), and two full bottles of Lactulose 10 Gram in Bedroom # two (2) accessible to residents in care. Additionally, review of R1's random medication revealed that the facility has a full completely sealed bottle of Atorvastatin 10MG to prevent heart attack, or stroke which was filled on 10/30/2023, with 100 tablets. A second empty bottle of Atorvastatin 10MG with one hundred (100) tablets, date filled on 02/20/2024, was observed empty. LPA did not observe any new bottle or any discontinuation notes on the Centrally Stored Medication and Destruction Record (LIC 622). LPA asked the Administrator and the staff for explaining and both staff could not provide any answers. A deficiency will be cited. Continue on LIC 809C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

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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Document Has Been Signed on 07/15/2024 05:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYALTY GUEST HOME, INC.	FACILITY NUMBER: 197606562
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)(2)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents...(1) Knives, matches, firearms...(2) Over-the-counter medication... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by providing care and supervision to persons with dementia and having sharps, medications, toxins, and gardening tools accessible to residents in care, which poses an immediate health and safety or pesonal rights risk to persons in care.
	POC Due Date: 07/17/2024
	Plan of Correction
1 2 3 4	Administrator will provide a training to all staff on the importance of maintaining sharps, medications, toxins, and gardening tools accessible to residents in care inaccessible to residents in care. The administrator shall submit staff sign in sheet with the topic and the training material to LPA by POC date.

Type A

Section Cited

CCR

87465(c)(2)

87465- Incidental Medical and Dental Care: c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in not assuring that R1's prescibed medications were given as prescribed, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/17/2024
	Plan of Correction
1 2 3 4	Administrator agreed to schedule vendorized training for all staff by 7/16/2024 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion.

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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYALTY GUEST HOME, INC.	FACILITY NUMBER: 197606562
	VISIT DATE: 07/15/2024

NARRATIVE

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Bedrooms: The facility has five (5) resident bedrooms of which three (3) were vacant. There was one room designated for staff. All resident bedrooms, including the vacant rooms, were properly furnished and supplied with appropriate bedding and linens. Rooms observed to have bedspread, sheets, pillowcase, LPA observed roaches in the resident’s bedrooms as well as spider webs in the ceiling. One of the vacant bedrooms also had a leak in the corner of the closet in the ceiling and the upper portion of the wall. Trash cans did not have any tight-fitting lids.

Bathrooms: LPA observed two (2) bathrooms and both needed to be clean. The sink in one of the bathrooms was clogged. LPA also observed two (2) bottles of Cloralen with bleach sprays in the bathroom cabinet accessible to residents in care. The bathrooms were properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and resident's bathroom had non-skid mat. At 10:41 AM, hot water temperature measured at 150°F.

Common Areas: The facility maintains a comfortable temperature at 78°F. The living room and dining area did not appear clean. They were furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. The fire extinguisher by the front door and in the kitchen were expired and were dated from 12/06/2018.

Outside areas: At approximately, 10:45 AM, LPA toured the outside area of the facility. There was a locked fenced area designated for laundry and laundry detergents were observed locked. The facility has four separate storage rooms. Two out of four storage rooms were observed unlocked of which one storage room had paints and other chemicals. All windows and door paths from inside and outside needed cleaning.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 10:55 AM they were tested and observed to be operational. Carbon monoxide was located in a hallway and was also tested and observed to be operational.

Continue on LIC 809C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYALTY GUEST HOME, INC.	FACILITY NUMBER: 197606562
	VISIT DATE: 07/15/2024

NARRATIVE

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Between 11:30 AM, to 1:00 PM, LPA reviewed records of two (2) residents and two (2) staff. LPA observed two out of two resident records were incomplete and missing forms. Appraisal/Needs and Services Plan (LIC 625) and Physician Report (LIC 602A) were missing. LPA observed that two (2) out of two (2) staff did not have valid/current First Aid/CPR training on file. Residents and staff records did not appear to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

Deficiencies cited during today’s visit. Appeal rights explained.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/15/2024 05:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYALTY GUEST HOME, INC.	FACILITY NUMBER: 197606562
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87203

Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA observed 2 fire extinguishers one in the kitchen area and the other in living room by the main exit that were purchased on 6/30/2018 and should be replaced every year which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 07/22/2024
	Plan of Correction
1 2 3 4	The facility will have the current fire extinguishers serviced or replaced by the POC due date. Proof of purchase or service will be submitted to LPA for review.

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation: a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based LPA observation licensee did not comply with the section sited above by having cockroaches at the facility (kitchen, living room, resident's bedrooms, bathrooms), moreover licensee did not comply with section cited above by not ensuring the entire facility was clean and free of odor. which poses a potential health and safety risk to residents in care.
	POC Due Date: 07/22/2024
	Plan of Correction
1 2 3 4	Licensee/ Administrator agreed to provide proof of treatment for cockroaches and plan to prevent the pests from spreading in the facility.Administrator will also provide a deep cleaning service invoice in order to remove the strong odor of the facility. The proof shall be submitted to LPA by POC date

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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYALTY GUEST HOME, INC.	FACILITY NUMBER: 197606562
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(a)

Resident Records/Incident Reports: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in not completing/updating two out of two resident's Appraisal/Needs and Services Plan (LIC 625), and the physician report (LIC 602) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/22/2024
	Plan of Correction
1 2 3 4	Licensee shall ensure to update and completle two out of two resident's Appraisal/Needs and Services Plan (LIC 625), and the physician report (LIC 602) Copy of updated forms shall be submitted to LPA by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYALTY GUEST HOME, INC.	FACILITY NUMBER: 197606562
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87211(a)(1)A,B,&D

Requirements: (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review the the licensee did not comply with the section cited above in two out of two incidents reports for two (2) residents to the Community Care Licensing Department (CCLD) in a timely manner which poses /posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/17/2024
	Plan of Correction
1 2 3 4	Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Copy of an incident shall be submitted to LPA by POC date.

Type B

Section Cited

CCR

87303(e)(2)

87303 Maintenance and Operation (e)(2) Faucets used by residents for personal care..... the temperature of hot water used by residents to attain a temperature of not less than 105-degree F (41 degree C) and not more than 120-degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the hot water temperature was measured at 150 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/22/2024
	Plan of Correction
1 2 3 4	Licensee will adjust water temperature and provide evidence to LPA and certify that water temperature has been adjusted and within range of 105 degrees F and 120 degrees F by 7/22/2024.

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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/15/2024 05:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYALTY GUEST HOME, INC.	FACILITY NUMBER: 197606562
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(f)(3)

87303 Maintenance and Operation (f) Solid waste shall be stored and disposed of as follows (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers… This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and observation Administrator failed to have container with tight fitting lids. This poses a potential health and safety risk or personal rights risk to residents in care.
	POC Due Date: 07/22/2024
	Plan of Correction
1 2 3 4	Administrator shall purchase new trash bins with lids and submit a receipt to the LPA by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

LIC809 (FAS) - (06/04)

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