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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608401
Report Date: 12/22/2021
Date Signed: 12/22/2021 03:55:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:VICTOR ROYALE, LLCFACILITY NUMBER:
197608401
ADMINISTRATOR:PETER BABAIANFACILITY TYPE:
740
ADDRESS:120 E. LAUREL STREETTELEPHONE:
(818) 243-7442
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:60CENSUS: 53DATE:
12/22/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Peter Babian-AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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On 12/22/2021 9:30 a.m. Licensing Program Analyst (LPA) , Nina Galarza conducted an unannounced Case Management visit. Purpose of the visit was to address deficiencies observed on 12/15/2021 during a complaint investigation. LPA met with administrator, Peter Babian and stated the purpose of the visit. On 12/15/21 LPA toured facility with Staff#1 (S1).

On 12/15/21 LPA observed:
  • No screenings of COVID-19 for temperature or symptoms were done for visitors of the facility
  • white picket fence on side of facility, adjacent to a walkway, with detached pieces of fence and broken pieces of fence
  • wooden fence on side of facility, adjacent to a walkway, with broken pieces of wooden fence
  • a wooden bench located in the back yard area with back support detached on one side.
  • a wooden bench located in the back yard area with metal support in disrepair.
  • window on door leading to back area with cracks in glass
  • utility door on side of facility, adjacent to walkway and wooden fence, off door hinge
  • water pipe on side of facility building, with a missing screw to secure water pipe in place
  • bathroom fixture in room 1 of cottage 1511 in disrepair, missing base and bar of towel rack.
  • door of room 1 in cottage 1511 with a crack
  • missing bathroom tile inside shower of shared bathroom in cottage 1511
  • wall in room 4 of cottage 1511 with a crack
  • window in room 3 of cottage 1511 with a crack


CONTINUED 809-C
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VICTOR ROYALE, LLC
FACILITY NUMBER: 197608401
VISIT DATE: 12/22/2021
NARRATIVE
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  • window screen in room 3 of cottage 1511 in disrepair and bent out of shape
  • window screen in bathroom of room 1 of cottage 1515 with a tear
  • window screen in room 6 of cottage 1515 with a tear
  • window screens in main facility in rooms 6,8,15,16,19,23, 29, 27, and bathroom window in room 2 with tears in screen
  • night stand in room 2 of cottage 1511 with missing drawer handle
  • wall in closet of room 3 of cottage 1515 in disrepair, with duct tape securing wall fixture
  • wood tiles near room 4 of cottage 1515 in disrepair and lifting from floor
  • planks of wood, metal chair, plastic chair, concrete dry wall, plastic bucket and plastic boxes blocking walkway on side of facility
  • bags of sand blocking walkway to patio area.
  • open paint cans outside of cottage 1511
  • closed paint cans in patio common area by vending machines
  • window of shower area with mold

Deficiencies cited under California Code of Regulations, refer 809-D

Exit Interview conducted, copy of report and appeal rights provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VICTOR ROYALE, LLC
FACILITY NUMBER: 197608401
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2021
Section Cited

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities ...personal rights:(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
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On 12/15/2021 LPA observed no screenings of COVID-19 for temperature or symptoms were done for visitors of the facility. Based on observation and interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
01/07/2022
Section Cited

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87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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On 12/15/2021 LPA observed white picket fence on side of facility, adjacent to a walkway, with detached pieces of fence and broken pieces of fence
wooden fence on side of facility, adjacent to a walkway, with broken pieces of wooden fence, a wooden bench located in the back yard area with back support detached on one side, a wooden bench located in the back yard area with metal support in disrepair. window on door leading to back area with cracks in glass, utility door on side of facility, adjacent to walkway and wooden fence, off door hinge, water pipe on side of facility building, with a missing screw to secure water pipe in place, bathroom fixture in room 1 of cottage 1511 in disrepair, missing base and bar of towel rack, door of room 1 in cottage 1511 with a crack, missing bathroom tile inside shower of shared bathroom in cottage 1511, wall in room 4 of cottage 1511 with a crack, window in room 3 of cottage 1511 with a crack. window of shower area with mold Based on observation, interview, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons 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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VICTOR ROYALE, LLC
FACILITY NUMBER: 197608401
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2021
Section Cited

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87307 Personal Accommodations and Services (d)The following space and safety provisions shall apply to all facilities:(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.
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On 12/15/21 LPA observed open paint cans outside of cottage 1511 closed paint cans in patio common area by vending machines, which poses an immediate Health and Safety risk to persons in care
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Type A
12/23/2021
Section Cited

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87307 Personal Accommodations and Services (d)The following space and safety provisions shall apply to all facilities:(6)All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by
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On 12/15/21 LPA observed planks of wood, metal chair, plastic chair, concrete, dry wall, plastic bucket and plastic boxes blocking walkway on side of facility, bags of sand blocking walkway to patio area, which poses an immediate Health and Safety risk to persons 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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VICTOR ROYALE, LLC
FACILITY NUMBER: 197608401
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/07/2022
Section Cited

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87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
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On 12/15/21 LPA observed window screen in room 3 of cottage 1511 in disrepair and bent out of shape, window screen in bathroom of room 1 of cottage 1515 with a tear window screen in room 6 of cottage 1515 with a tear, window screens in main facility in rooms 6,8,15,16,19,23, 29, 27, and bathroom window in room 2 with tears in screen. Based on observation, interview, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons 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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5