197608401-1-28-2022-28-AS-NMAN-CB53E8-20220128171043

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608401
Report Date: 01/28/2022
Date Signed: 01/28/2022 05:10:48 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, LLC		FACILITY NUMBER:	197608401
ADMINISTRATOR:	PETER BABAIAN		FACILITY TYPE:	740
ADDRESS:	120 E. LAUREL STREET		TELEPHONE:	(818) 243-7442
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91205
CAPACITY:	60	CENSUS: 52	DATE:	01/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Administrator Peter Babaian and Assistant Administrator Alise Nazarian		TIME COMPLETED:	05:15 PM

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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced Required One (1) year - Inspection to this facility. Upon arrival, LPA met with Administrator Peter Babaian and Assistant Administrator Alise Nazarian who assisted with the visit. The purpose of the visit was explained. Facility is licensed to serve 49 Non-Ambulatory residents; of which four (4) may be bedridden. Facility is approved to retain/accept six (6) hospice residents. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed residents and staff files. Facility has submitted a mitigation plan and the plan has been approved.

LPA 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. LPA observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways are free of obstruction.

There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask during this visit.

LPA toured randomly selected residents rooms. All bedrooms were furnished with required furnitures. The bathrooms were observed to be clean, operational and equipped with grab bars and non-skid mats. The hot water temperature was tested throughout the facility and measured within Title 22 Regulations guidelines.
Common areas such as the dining room, hallways, Activity / TV room, no smoking patio were inspected. All areas were clean and had the required furniture. There is a smoking area in the back of facility/ shaded outside patio.

Continued 809C

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VICTOR ROYALE, LLC	FACILITY NUMBER: 197608401
	VISIT DATE: 01/28/2022

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The kitchen was toured. All appliances were clean and operating properly. There was a sufficient amount of perishable and non-perishable food. Smoke and carbon detectors were in good repair. The fire extinguishers observed to be fully charged. LPA observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations.

LPA reviewed 6 residents and 4 staff records. Residents' records were found to be complete and current. Staff files were reviewed and documentation noted that facility staff maintain a criminal record clearance and associated to the facility. LPA randomly chose some residents' medications to review. Medications are documented properly and stored appropriately.

Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit. A copy of the report was provided to the administrator.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

LIC809 (FAS) - (06/04)

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