197607361-4-5-2022-31-AS-JMAZ-CD7T3R-20220405142245

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607361
Report Date: 04/05/2022
Date Signed: 04/05/2022 02:23:42 PM

Document Has Been Signed on 04/05/2022 02:23 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 PALMS		FACILITY NUMBER:	197607361
ADMINISTRATOR:	NATALIE MALLON		FACILITY TYPE:	740
ADDRESS:	20548 GERMAIN STREET		TELEPHONE:	(818) 772-7153
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	6	CENSUS: 6	DATE:	04/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	John Mallon		TIME COMPLETED:	02:35 PM

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Licensing Program Analyst (LPA) Joscelyn Martinez conducted an unannounced annual inspection. Upon arrival LPA met with staff and later met with Administrator John Mallon. The purpose of the visit was explained.

At 12:25 p.m. LPA conducted a physical tour of the facility. Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Upon entrance, staff took LPA’s temperature and was asked to sign-in the visitor’s log. Facility has sufficient PPE supplies for more than 30 days. Food Inspection/Kitchen: LPA Martinez observed there was sufficient stock of one-week non-perishable foods and two-day perishable foods. Sharps and medications are centrally stored in a locked area. At 12:39 p.m. LPA observed cleaning chemicals accessible to residents under the sink cabinet. Staff took the chemical and properly stored them to keep them inaccessible to residents. Smoke detectors/carbon monoxide are located throughout the facility and are hardwired. Smoke detectors and carbon monoxide detectors were tested at 1:00 p.m. and appear to be functional. Fire extinguisher has a purchase date of 05/05/2021. Common Areas: All common areas were observed to be clean and properly furnished. Facility maintains a temperature of 78.0 F. Residents Rooms: There are seven (7) bedrooms which of one (1) is designated for live-in staff use. All bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

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 PALMS	FACILITY NUMBER: 197607361
	VISIT DATE: 04/05/2022

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Bathrooms: There are three (3) bathrooms in the facility. LPA observed all bathrooms to have grab bars and non-skid mats. The hot water was tested and measured at 109.7 F. At 12:44 p.m cleaning solutions were observed under the bathroom sink. Staff properly stored the cleaning solutions at the time of the visit. Garage: There is an additional laundry room that leads into the garage. The attached garage is being used for additional storage. Garage is locked and inaccessible to residents. Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There is a body of water that is kept locked and inaccessible to residents.

Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

Exit Interview Conducted / Citations issued/Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/05/2022 02:23 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYAL PALMS	FACILITY NUMBER: 197607361
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/05/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/06/2022 Section Cited	1 2 3 4 5 6 7	87705(f(2)Care of Persons with Dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on observation, licensee failed to ensure that cleaning chemicals were properly stored and inaccessible to residents, which is an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC809 (FAS) - (06/04)

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