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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606562
Report Date: 06/19/2025
Date Signed: 06/19/2025 05:03:10 PM

Document Has Been Signed on 06/19/2025 05:03 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/
DIRECTOR:		ELENA ANGUSTIAFACILITY TYPE:
740
ADDRESS:20609 BRYANT STREETTELEPHONE:
(818) 727-1741
CITY:CANOGA PARKSTATE: CAZIP CODE:
91306
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
06/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:39 AM
MET WITH:Elena Angustia - AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 6/19/25 an unannounced annual visit was conducted by Licensing Program Analyst (LPA) Perchui Milena Khurshudyan. Upon arrival, LPA met with the facility Administrator Elena Angustia, who granted access to the facility. LPA introduced herself by showing her badge and explained the reason for the visit. LPA Khurshudyan reviewed the required postings on a wall throughout the facility. The inspection tool was used to complete today's visit.

During today's visit, LPA conducted a physical plant walk through at approximately 10:55am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22.The following was observed: The facility is a single-story home and is licensed for capacity of six (6) residents, of which six (6) may be non-ambulatory and of which fire clearance for one (1) Bedridden. Facility also has a hospice waiver for one (1) resident. There are five (5) bedrooms designated for residents’ use. All bedrooms observed to be appropriately furnished and have appropriate lighting. There are two (2) bathrooms in the facility designated for residents’ and staff use. LPA observed bathrooms have soap, paper towels and hand washing signs. The hot water temperature measured at 11:15am to be 123.1°F. Extra towels and linens were readily available in the linen closet located in the hallway. There are grab bars for each toilet and shower, bathrooms have non-skid mats. All trash cans in bathrooms had fitted lids to protect from cross contamination. LPA observed facility alarms were present on all exit doors and signals were operational.

SMOKE DETECTORS/CARBON MONOXIDE. The smoke detectors and carbon monoxide are hard wired, inter-connected and were located throughout the facility. At 12:30pm they were tested and observed to be operational. The facility has two (2) fire extinguishers that was last purchased on 7/16/2024.

Continue on LIC809-C

Nichelle GillyardTELEPHONE: (818) 596-4370
Perchui KhurshudyanTELEPHONE: (818) 439-7073
DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2025
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 11
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 11
Document Has Been Signed on 06/19/2025 05:03 PM - It Cannot Be Edited


Created By: Perchui Khurshudyan On 06/19/2025 at 03:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87706(a)(1)(C)
Advertising Dementia Special Care, Programming, and Environments
(a) In addition to the requirements in Section 87705, Care of Persons with Dementia, licensees who advertise, promote, or otherwise hold themselves out as providing special care, programming, and/or environments for residents with dementia or related disorders shall meet the following requirements: (1) In addition to the requirements specified in Sections 87208, Plan of Operation, the licensee shall include in the plan of operation a brief narrative description addressing the following additional information: (C) Staff training describing the required training for direct care staff who provide dementia special care. At a minimum, the description shall include information on training to be provided, as specified in Health and Safety Code sections 1569.625 and 1569.626.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above not providing required training, monthly in-services, (training is important due to the level of care for the clients) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2025
Plan of Correction
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Licensee / Administrator agreed to provide training to all staff members. Copy of proof will 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (818) 596-4370
Perchui Khurshudyan
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (818) 439-7073
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2025


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 06/19/2025 05:03 PM - It Cannot Be Edited


Created By: Perchui Khurshudyan On 06/19/2025 at 03:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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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, accessible to residents in care, which poses an immediate health and safety or personal rights risk to persons in care.
POC Due Date: 06/23/2025
Plan of Correction
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Administrator will provide a training to all staff on the importance of maintaining sharps, medications, toxins, 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
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by storing chemicals unlocked and near the food and medications, which poses an immediate health and safety or personal rights risk to persons in care.
POC Due Date: 06/23/2025
Plan of Correction
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Administrator will provide a training to all staff on storage of disinfectants, cleaning solutions, and poisonous substances in areas separate from food supplies as specified in Section 87555, General Food Service Requirements. The administrator shall submit staff sign in sheet with the topic and the training material 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (818) 596-4370
Perchui Khurshudyan
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (818) 439-7073
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2025


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 06/19/2025 05:03 PM - It Cannot Be Edited


Created By: Perchui Khurshudyan On 06/19/2025 at 03:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above. CPR training were observed for all three staff were last completed in 2019, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2025
Plan of Correction
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Administrator will provide CPR certificates for all staff working in the facility.
Type A
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by storing chemicals unlocked and near the food, which poses an immediate health and safety or personal rights risk to persons in care.
POC Due Date: 06/23/2025
Plan of Correction
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Administrator will provide a training to all staff on storage of Soaps, detergents, cleaning compounds or similar substances in areas separate from food supplies. The administrator shall submit staff sign in sheet with the topic and the training material 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (818) 596-4370
Perchui Khurshudyan
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (818) 439-7073
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2025


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 06/19/2025 05:03 PM - It Cannot Be Edited


Created By: Perchui Khurshudyan On 06/19/2025 at 03:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation Licensee/Administrator did not comply with the section cited above. LPA observed breakfast area is cluttered, unorganized and not sanitary. LPA also informed that there is a cockroach in the facility. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2025
Plan of Correction
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The Licensee will provide a picture of a clean kitchen and breakfast area to LPA by POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (818) 596-4370
Perchui Khurshudyan
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (818) 439-7073
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2025


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 06/19/2025 05:03 PM - It Cannot Be Edited


Created By: Perchui Khurshudyan On 06/19/2025 at 03:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the the licensee did not comply with the section cited above by not providing an incidents report to the Community Care Licensing Department (CCLD) in a timely manner for one (1) resident being hospitalized for UTI, which poses /posed a potential health, safety or personal rights risk to persons in care.

POC Due Date: 06/23/2025
Plan of Correction
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Licensee/Administrator 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
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, Licensee did not comply with the section cited above. LPA observed that the liability insurance has coverage for injury to residents and guests in the amount of one million dollars ($1,000,000) per occurrence and two million dollars ($2,000,000) in the total annual aggregate, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2025
Plan of Correction
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Licensee/Administrator will submite amended liability insurance coverage to LPA by POC due 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (818) 596-4370
Perchui Khurshudyan
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (818) 439-7073
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2025


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 06/19/2025 05:03 PM - It Cannot Be Edited


Created By: Perchui Khurshudyan On 06/19/2025 at 03:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)(2)(A)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (2) Any items in subsection (a)(1) that are transferred from their original container to another container shall have a legible label that indicates: (A) Name of product on the original container, and

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 leaving sharps/knives unlocked inside the kitchen cabinet, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2025
Plan of Correction
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2
3
4
Administrator will provide a training to all staff on the importance of maintaining sharps 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 B
Section Cited
HSC
1569.618(c)(4)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on 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: 06/23/2025
Plan of Correction
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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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (818) 596-4370
Perchui Khurshudyan
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (818) 439-7073
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2025


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 06/19/2025 05:03 PM - It Cannot Be Edited


Created By: Perchui Khurshudyan On 06/19/2025 at 03:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(22)
General Food Service Requirements
(b) The following food service requirements shall apply: (22) Adequate space shall be maintained to accommodate equipment, personnel and procedures necessary for proper cleaning and sanitizing of dishes and other utensils.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation Licensee/Administrator did not comply with the section cited above. LPA observed living room and the kitchen area is cluttered, unorganized and not sanitary. Kitchen items and other items not related to kitchen area were storted on the kitchen counters and on the kitchen table. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2025
Plan of Correction
1
2
3
4
The Licensee /Administrator will provide a picture of a clean, organized and saniatry kitchen and breakfast area to LPA by 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (818) 596-4370
Perchui Khurshudyan
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (818) 439-7073
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2025


LIC809 (FAS) - (06/04)
Page: 9 of 11
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: 06/19/2025
NARRATIVE
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KITCHEN: The facility has a Kitchen area that is equipped with a two (2) refrigerators, microwave oven, dish washer and sink. The kitchen appliances and fixtures were functional. LPA observed the kitchen area to be dirty and not sanitary. There was sufficient stock of one-week non-perishable foods and two days of perishable foods. Stored foods were not properly labeled. Food storage and preparation areas observed to be cluttered and unorganized. LPA observed that sharp objects were stored inside the unlocked kitchen cabinet and accessible to residents in care. LPA also observed chemical bug spray on the kitchen floor and informed by the caregiver that there is a cockroach in the facility. Extra emergency food was also stored inside the kitchen cabinets. Temperature was measured at 12:35pm to be 81°F.

MEDICATION: LPA observed centrally stored medication unlocked inside one of the staff’s unlocked room and numerous medications openly placed on the kitchen table. First Aid kit was locked inside the hallway storage cabinet, inaccessible to residents in care and it was checked by the LPA to be complete. Facility has two (2) staff for AM shift and one (1) awake caregiver for PM shift.

COMMON AREAS: LPA observed the living room and the dining room to be generally clean and furnished, however, the area was cluttered by files, documents, papers etc. Facility has land line; LPA checked its operational. There is a fireplace, which is blocked by the sofa and LPA was informed that the fireplace is not-operational.

LAUNDRY ROOM: Laundry machines are located outside of the facility inside locked fenced area. LPA observed chemicals stored openly in the kitchen and staff room areas, available to residents residing in the facility. LPA discussed the importance of keeping potentially dangerous items locked at all times.

SURROUNDING GROUNDS: LPA observed sufficient yard space with fenced backyard. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. Exit doors were unlocked however, obstructions were observed on the exit areas. The facility does not have a swimming pool or body of water.

FILE REVIEW: Between 11:00am to 12:30pm, LPA reviewed records and files of two (2) residents and three (3) staff/caregivers. A review of staff and resident records appeared to be not complete. There are no residents with prohibited conditions residing at the facility.

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui KhurshudyanTELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC809 (FAS) - (06/04)
Page: 10 of 11
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: 06/19/2025
NARRATIVE
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An emergency exit plan/sketch along with other posting requirements are posted on the wall by the entrance area.

Medications Review: At approximately 12:35pm LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. All medications were properly recorded, however, PRN medications did not have written orders from a physicians.

LPA collected LIC500, LIC9020, copy of Liability Insurance Certificate.

Deficiencies issued during today’s visit.

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

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui KhurshudyanTELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC809 (FAS) - (06/04)
Page: 11 of 11