197608129-5-18-2026-29-AS-QHUH-DU7TND-20260518145234

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608129
Report Date: 05/18/2026
Date Signed: 05/18/2026 02:53:01 PM

Document Has Been Signed on 05/18/2026 02:53 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, THE		FACILITY NUMBER:	197608129
ADMINISTRATOR/ DIRECTOR:	ANGELITO VITUG		FACILITY TYPE:	740
ADDRESS:	12229 CHANDLER BOULEVARD		TELEPHONE:	(818) 980-2997
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY: 96		CENSUS: 89	DATE:	05/18/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Riza Vitug - Assistant Adminstrator Lito Vitug - Executive Director		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 10:00AM for a required one-year visit. The LPA met with Assistant Administrator (AA) Riza Vitug and Executive Director (ED) Lito Vitug arrived at 11:10AM. Entrance interview conducted. At 10:16AM, the LPA and AA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: RESIDENT ROOMS: The LPA observed ten (10) randomly selected rooms with private restrooms on the first and second floor and no immediate health or safety hazards were observed. Restrooms were clean, with properly installed grab-bars and non-skid mats in showers. Resident rooms were furnished with all required furniture within regulation. Water temperature was tested throughout the units and measured between 116.8 degrees F and 121.5 degrees F. The water temperature was lowered during the visit. COMMON AREAS: The facility is a two-story building with a total of eighty-eight (88) units. On the first floor, there are the kitchen facilities, dining room, laundry room, lobby, outdoor lobby/smoking area, medication room, staff offices, common restrooms, and outdoor courtyard. On the second floor, there are common restrooms, library, and common/activity space. Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

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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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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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
	VISIT DATE: 05/18/2026

NARRATIVE

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The LPA observed common areas to be clean and contain furniture in good condition. There were no obstructions and/or tripping hazards throughout the facility. There were cameras in the common areas, outdoor courtyard, and exterior perimeter. Required postings were found in the hallways on the first floor. LPA observed electric stair lifts in the staircases in the event of an emergency. There were no bodies of water observed during today’s visit.

KITCHEN: Facility dining room and commercial kitchen were inspected and in compliance with Title 22 regulations. There was a sufficient supply of perishable and non-perishable food. The refrigerator and freezer were maintained with the required temperatures. Food appeared to be of good quality and labeled appropriately.

MEDICATION: Medication review began at 11:05AM. The LPA reviewed medications for three (3) residents. Medications are maintained locked inaccessible to residents in an attached room behind the concierge desk located on the first floor. Resident medications reviewed were documented and stored in compliance with regulation at this time. The LPA reviewed records and reporting requirements regarding medication refusals. It was observed that the facility did not have an adequate system of documenting notifications of medication refusals of residents’ physicians and responsible parties.

RECORDS: Resident records were reviewed at 12:40PM. The LPA reviewed five (5) resident records for, but not limited to admissions agreements, consent forms, medical assessments, and appraisals. Records were in order at this time. Five (5) personnel records were reviewed for, but not limited to job application, health assessments, TB results, criminal record statements and clearances, first aid/CPR certification, and staff trainings. Records reviewed were in order.

Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: RESIDENCES AT ROYAL BELLINGHAM, THE	FACILITY NUMBER: 197608129
	VISIT DATE: 05/18/2026

NARRATIVE

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EMERGENCY DISASTER/INFECTION CONTROL: The LPA reviewed the facility's Emergency Disaster Plan and Infection Control Plan and is in compliance with regulation. Emergency food and water were observed in a secured closet on the first floor. The facility conducts emergency disaster drills as required with the last drill documented on 02/26/2026. Fire alarm systems were last inspected on 11/05/2025 by Advance Building Protection. Fire extinguishers were observed throughout the facility and last serviced on 03/26/2026.

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

Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/18/2026 02:53 PM - It Cannot Be Edited

Created By: Quoc Huynh On 05/18/2026 at 02:31 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: 05/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87466

Observation of the Resident

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in residents' medication refusal notifications were not properly documented which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/22/2026
	Plan of Correction
1 2 3 4	The Licensee will provide staff training on resident observations, notifications of physicians and reponsible parties, and maintaining documentations and provide proof to CCLD by POC due date.

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.

	Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:

	Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

LIC809 (FAS) - (06/04)

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