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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608129
Report Date: 03/03/2023
Date Signed: 03/03/2023 09:21:48 AM


Document Has Been Signed on 03/03/2023 09:21 AM - 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. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:RESIDENCES AT ROYAL BELLINGHAM, THEFACILITY NUMBER:
197608129
ADMINISTRATOR:LORI MCKAYFACILITY TYPE:
740
ADDRESS:12229 CHANDLER BOULEVARDTELEPHONE:
(818) 980-2997
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:96CENSUS: 84DATE:
03/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Joey Vitug - Assistant AdministratorTIME COMPLETED:
09:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management – Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20210428161634). The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.

During the course of the investigation it was revealed that Resident #1 (R1) had a change in condition, however the facility failed to conduct a reappraisal.

Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC 809-D).

Exit interview conducted. Citation issued. Appeal Rights discussed and a copy of the report was issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2023
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 2


Document Has Been Signed on 03/03/2023 09:21 AM - 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. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: RESIDENCES AT ROYAL BELLINGHAM, THE
FACILITY NUMBER: 197608129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/10/2023
Section Cited

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87463(a)(3) Reappraisals. (a) The
pre-admission appraisal shall be updated, in
writing as frequently as necessary to note
significant changes...(3) Any illness, injury,
trauma, or change in the health care needs of
the resident that results in a circumstance or condition...
This requirement is not met as evidenced by:
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The Administrator agreed to submit a Statement of understanding, detailing how the facility will maintain compliance of 87463(a)(3) and submit to LPA via email by EOD 3/10/2023.
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Based on interviews and record review, licensee did not comply with the section cited above as R1's reappraisal was not updated to reflect change of condition after being discharged from the hospital, which poses a potential health and safety risk to residents in care.
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2023
LIC809 (FAS) - (06/04)
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