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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608129
Report Date: 07/02/2025
Date Signed: 08/29/2025 01:47:18 PM

Document Has Been Signed on 08/29/2025 01:47 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
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: 96CENSUS: 91DATE:
07/02/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Rizaandrea Vitug - Assistant Administrator TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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This report has been amended to reflect revised wording. A telephonic review was conducted on August 29, 2025, at 1:43 p.m. with Rizaandrea Vitug - Assistant Administrator to confirm the changes. LPA emailed the amended report for signature, and it will remain on file.

Licensing Program Analyst (LPA) Erica Mosley conducted a Case Management - Deficiencies visit.
During the Department’s investigation of complaint # 29-AS-20250220154549, the following deficiencies were observed. On 12/30/2024, Resident #1 (R1) reported to the Administrator that R1 was sexual assaulted by Staff #1 (S1) during the evening of 12/29/2024. However, the Administrator did not submit the Unusual Incident/Injury Report (UIR) to Community Care Licensing (CCL) until 01/08/2025. Due to the nature of the allegation, the suspected abuse should have been reported within 24 hours to CCL, Long Term Care Ombudsman (LTCO), and the local police. In addition, the information in the UIR was incorrect. The Administrator reviewed the facility Ring video footage on 12/30/2024 and discovered that S2 had entered R1's room the night before. Both the facility Supervisor and the Administrator were aware S2 entered R1’s room on the night of the incident and not S1. However, the incident report only reflected what R1 reported to the Administrator.

The facility manager stated that staff were sleeping in the basement room which also serves as a lounge for employees and did not see anything wrong with the employees living in the basement room.

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

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document is an Amendment of Original Document on 08/29/2025 01:35 PM


Created By: Erica Mosley On 07/02/2025 at 12:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, THE
FACILITY NUMBER: 197608129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2025
Section Cited
CCR
87211(c)

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87211 Reporting Requirements (c) Any suspected physical abuse... shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours ... This requirement is not met as evidenced by:
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Administrator agrees to review 87211 Reporting Requirements. Submit memo of understanding regarding reporting requirements, including Mandated Reporting, to CCL, LPA Mosley via email by 07/02/2025.
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Based on records review and interviews, the licensee did not comply with the section cited above. Administrator submitted the incident report late and with incorrect information, which posed an immediate health and safety risk to residents in care.
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Type A
07/02/2025
Section Cited
CCR87405(d)(2)(5)

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87405(d)(2)(5) Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(5) Good character and a continuing reputation of personal integrity.This requirement is not met as evidenced by:
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Administrator agrees to review Reg.87405(d)(2)(5) Submit memo of understanding regarding regulation by 07/02/2025 and train staff on 87405(d)(2)(5) and submit proof to CCLD , LPA Mosley by 07/16/2025.
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Based on records review and interviews, the licensee did not comply with the section cited above. Administrator did not follow the reporting requirements for suspected abuse which posed an immediate 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Erica Mosley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/02/2025 02:08 PM - It Cannot Be Edited


Created By: Erica Mosley On 07/02/2025 at 12:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2025
Section Cited
CCR
87307(a)

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87307(a) Personal Accommodations and Services (a)Living accommodations and grounds shall ...comfortable living accommodations and privacy for the residents, staff... (1) There shall be ...prevent such activities from interfering with other functions. This requirement is not met as evidenced by:
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Licensee/Administrator agreed to not allow staff sleeping in this area and clear out all furniture (bed) and submit photos to LPA Mosley by 07/16/2025. Licensee/Administrator agreed to submit 24hr staffing schedule (LIC500) by POC date.
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Based on interviews and observation, the licensee did not comply with the section cited above. Staff are sleeping in the basement room which also serves as a lounge for employees, 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Erica Mosley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
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