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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608129
Report Date: 01/31/2025
Date Signed: 01/31/2025 11:48:16 AM

Document Has Been Signed on 01/31/2025 11:48 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:RESIDENCES AT ROYAL BELLINGHAM, THEFACILITY NUMBER:
197608129
ADMINISTRATOR/
DIRECTOR:		LORI MCKAYFACILITY TYPE:
740
ADDRESS:12229 CHANDLER BOULEVARDTELEPHONE:
(818) 980-2997
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY: 96TOTAL ENROLLED CHILDREN: 0CENSUS: 88DATE:
01/31/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:59 AM
MET WITH:Lito VitugTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst Trevor Bryne conducted an unannounced Case Management inspection regarding a self-reported Death Report (LIC 624) received. LPA met with facility Administrator Lito Vitug at 09:59 AM and explained the reason for the inspection.

On 01/27/2025, Community Care Licensing (CCL) received a self-reported Death Report (LIC 624) pertaining to the death of Resident #1 (R1) which occurred on 01/27/2025. During today’s visit between 10:02 AM and 11:35 AM, the LPA conducted an interview with the facility Administrator, two (2) staff members. LPA also conducted a brief physical plant tour and obtained copies of pertinent information.

No deficiencies were observed during today’s inspection. If warranted upon further review of information and documentation received, the LPA will return to investigate this further.

Exit interview conducted. A copy of the report was provided.
Kasandra LopezTELEPHONE: (818) 596-4343
Trevor ByrneTELEPHONE: 747-444-6104
DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2025
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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