197608401-12-22-2022-28-AS-ACAN-CMCRD9-20221222115535

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608401
Report Date: 12/22/2022
Date Signed: 12/22/2022 11:55:39 AM

Document Has Been Signed on 12/22/2022 11:55 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
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: 55	DATE:	12/22/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator Peter Babaian		TIME COMPLETED:	12:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ashley Calderon conducted a unannounced case management visit in relation to an fire damage that was reported to Community Care Licensing. Upon arrival, LPA met with LVN Amy Smbapuni and explained the purpose of the visit. Shortly after, the Administrator Peter Babaian arrived and assisted with the visit.

On today's visit, LPA interviewed Administrator, staff #1(S1), resident #1 (R1) and interviewed repair contractor via telephonically. LPA toured the cottage building number #1511 with Amy and observed cottage was locked and inaccessible to the residents. LPA observed no residents were living in the cottage and all residents based on interview with Babaian and Smbapuni were relocated to the main building the day fire incident that occurred on 11/02/22. LPA collected supportive documents: Insurance Company Claim documentation, RestCon Environmental of Southern California and VIC's Inc CA Contractor.

Administrator stated on 11/02/22 Fire Department came to put out the fire meanwhile staff safety removed all residents and used the fire extinguisher to help control the fire. Administrator stated no residents or staff members were injured. Administrator reported that a total of six residents were relocated and five rooms are inaccessible until repairs are completed for the health and safety of the residents .In addition on 11/02/22, Glendale Community Development Building and Safety placed a unauthorized entry sign in front of the cottage building and sign states the structure / site has been damage and is unsafe. On 11/03/22, Glendale Fire Department Specialist Eric Briggs toured the cottage to investigate how the fire occurred, no report was provided. Administrator stated on 11/7/22, a repair contractor named Jacob Harold from Four Seasons Remolding and Design provided and estimate on repairs needed. Administrator stated repairs will start once Insurance Company Carrier called Seneca Insurance Company completes the investigates on the open claim #22KKN026 which is in progress.

No deficiencies observed during the visit.

Exit interview conducted and a copy of the report was provided to administrator Peter Babaian.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

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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