197608129-5-25-2021-29-AS-ASMH-C3CQ7Z-20210525115557

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608129
Report Date: 05/25/2021
Date Signed: 05/25/2021 11:56:11 AM

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, THE		FACILITY NUMBER:	197608129
ADMINISTRATOR:	LORI MCKAY		FACILITY TYPE:	740
ADDRESS:	12229 CHANDLER BOULEVARD		TELEPHONE:	(818) 980-2997
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	96	CENSUS: 68	DATE:	05/25/2021
TYPE OF VISIT:	Required - 1 Year	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lito Vitug and Lori McKay		TIME COMPLETED:	12:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 10am. This annual had a specific emphasis on infection control practices and procedures. Administrators Lori McKay and Lito Vitug arrived at 11:10am, and the LPA explained the reason for the visit.

At 10:26am, the LPA toured the physical plant ensure there were no immediate health and safety hazards. At 10:31am, the LPA observed accessible disinfectant in the hallway. At 10:32am, the LPA observed that a room was being painted, yet the painting supplies were accessible in the hallway. At 10:33am, the LPA observed a janitorial cart in the hallway with accessible cleaning supplies. At 10:34am, the LPA observed an unlocked laundry room with accessible laundry detergent and disinfectant. This door was secured upon observation.

INFECTION CONTROL: The LPA spoke with the Administrator regarding the facility’s infection control practices. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. Upon entry, the LPA observed that not all staff were wearing a face covering. The LPA observed an adequate supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol is sufficient. If needed, the facility can designate a single isolation room if there is a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

The following recommendations were made:
- Testing Protocol, to ensure that 25% of staff are being tested weekly
- Appropriate signage to remind staff and residents of cough etiquette, visitation policies, hand hygiene, etc.
- Posting Provider Information Notices (PINs) and informing staff and residents of pertinent changes

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: RESIDENCES AT ROYAL BELLINGHAM, THE	FACILITY NUMBER: 197608129
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/25/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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, as there were accessible disinfectants and cleaning solutions observed during the visit, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/25/2021
	Plan of Correction
1 2 3 4	The Administrator has agreed to do the following: 1. Items were secured during today's visit. Plan of Correction met.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

LIC809 (FAS) - (06/04)

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