197606562-5-12-2022-31-AS-MCAA-CECUHF-20220512153548

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606562
Report Date: 05/12/2022
Date Signed: 05/12/2022 03:36:38 PM

Document Has Been Signed on 05/12/2022 03:36 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:	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: 3	DATE:	05/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Elena Angustia, Melencio Augustia		TIME COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) Michael Cava conducted an annual infection control inspection. LPA met with the administrator, Elena Angustia and assistant Melencio Angustia and advised them of the visit. The current census is three (3). Facility license and sketch, rights of resident council, grievance/complaint procedures, emergency disaster plan, resident bill of rights, personal rights, and neighborhood complaint procedures are visibly posted. Annual fees are current and administrator certificate expires 8/28/2022 which is current and valid.

A physical plant tour of the facility inside and outside was conducted with the Administrator and her assistant. The following common areas: living, dining, kitchen, resident bedrooms, bathrooms, staff room and office, were inspected to ensure the facility was in compliance with Title 22 Regulations:

Kitchen/Food Supply: Food service area had Licensing requirement of (7) day nonperishable, and (2) day perishable. Food was properly stored in a healthy manner. Snacks and beverages are available for clients. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas were clean and inaccessible to pests. Appliances were functional and clean. Chemicals, household supplies, and knives, and medication was locked and secured.

Living/dining/family/staff area and office: All indoor passageways were free from obstruction; inside temperature was comfortable and set at 79 degrees, with adequate lighting, and all areas were clean and appropriately furnished for resident’s comfort.

Bedrooms: The facility has five (5) resident bedrooms of which two 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,

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

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: ROYALTY GUEST HOME, INC.	FACILITY NUMBER: 197606562
	VISIT DATE: 05/12/2022

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mattress pad, and blankets, which were all in good repair. There were sufficient linens and towels observed and available.

Bathrooms: There are two (2) bathrooms; all were clean, with soap and towels, grab bars, and non-skid mats. Hot water measured in resident’s bathroom at 120 degrees Fahrenheit.

Surrounding Grounds: Smoke alarms and carbon monoxide detectors were tested and operating properly. Fire extinguisher was just recently purchased and is fully charged. First aid kit furnished and fully equipped. Exit doors have alarms; all were operating. There were no visible hazards, and passageways were free from obstruction. There is a patio in the backyard with appropriate seating for residents when sitting outside. There are no bodies of water (swimming pool, water fountain) present. The front yard/driveway posed no immediate health and safety threat to the residents in care.

Pursuant to title 22, division 6, chapter 8, there were no deficiencies observed during the day's inspection. 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: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC809 (FAS) - (06/04)

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