197608401-1-20-2023-28-AS-VMAO-CN9SDK-20230120124716

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608401
Report Date: 01/20/2023
Date Signed: 01/20/2023 12:47:27 PM

Document Has Been Signed on 01/20/2023 12:47 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
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: 54	DATE:	01/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Peter Babaian- Administrator		TIME COMPLETED:	01:15 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) V. Maldonado made an unannounced visit to the facility for the purpose of conducting the required annual inspection, using the Infection Control tool to evaluate the facility. LPA Maldonado met with staff Amy Smbatuni and explained the purpose for the visit. LPA conducted a tour of the physical plant with Amy, observed the food supplies, COVID-19 procedures, and reviewed resident and staff files, and resident's medications. The facility has an approved mitigation plan on file. Assistant Administrator Alise Nazarian and Administrator Peter Babaian arrived shortly after to assist with the visit. The facility is a one-story building located in a residential area. It is licensed to serve (60) elderly residents, ages 60 and over, of which (49) may be non-ambulatory and (4) may be bedridden in rooms# 11 and #28 only. The property also has (2) cottages, #1511 & #1515 reserved for ambulatory residents only and has a hospice waiver approved for (6). The building consists of a living room, kitchen, dining room, 29 resident bedrooms with restrooms, common showers and bathrooms with required grab bars and non-skid mats, a laundry room/storage located in the basement, and a shaded patio in the backyard with seating. The cottages are located across the back yard and each have 4 bedrooms with a shared bathroom/shower, which had the required grab bars and non-skid mats. LPA observed resident bedrooms# 4, 7, 23, and 29 to have the required furniture, bedding, linens, sufficient lighting, closet space, and additional storage space. Each room had a bathroom and were observed to have a toilet with the required grab bars and a wash basin. The water temperature was tested in the bathrooms of each room observed and in cottage# 1511, and measured between 113F-119F, which is in compliance with Title 22 Regulations. The food supplies was observed to be the required 2-day perishables and 7-day non-perishables. During the food inspection, LPA observed several canned food items to have expiration dates of October 2022- December 2022, and some of those cans appeared inflated and others were popped and spilling. Staff stated were unaware as some of the food had just arrived in their recent food delivery from the company they regularly order from. (Report continued on LIC809-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

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: 01/20/2023

NARRATIVE

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Several fire extinguishers were observed throughout the building and in the cottages to have current inspections and were fully charged. All sharps were observed to be locked and inaccessible in the kitchen. Cleaning supplies were locked and inaccessible, stored in cabinets in the basement and in a storage shed in the back yard. All laundry and kitchen equipment was operational and in good repair. The smoke/carbon monoxide detectors were tested, were interconnected and operational at the time of the visit. LPA observed a 30-day supplies of Personal Protective Equipment (PPE) stored in the basement, storage shed in the backyard, and in a hallway closet. Siganage was observed throughout the facility to promote hand washing, cough/sneeze etiquette, and social distancing. Communal hand washing stations were fully stocked with liquid soap and automatic hand dryers. Resident handwash sinks, located in their room bathrooms, were observed to not have liquid soap or paper towels- they had cloth towels and bar soaps. There is one central entry point for universal entry screening, as required by the COVID-19 guidance.

(5) random resident files were reviewed and had updated emergency contact information and health screenings. (3) random staff files were reviewed and had Criminal Background Clearances, health screenings, and proof of required annual training and certifications. (5) resident medications were reviewed and are documented properly and administered as prescribed.

Per California Code of Regulations, Title 22, and Health and Safety Codes, deficiencies were observed and will be cited on the LIC809-D.

An exit interview was conducted with Administrator Peter Babaian and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/20/2023 12:47 PM - It Cannot Be Edited

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: 01/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and iinterview, the licensee did not comply with the section cited above in several cans of food located in the kitchen, emergency supplies, and in the basement were expired, were inflated, and some were popped and spilling, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/27/2023
	Plan of Correction
1 2 3 4	Administrator will have staff inspect all food items in the facility and discard all damaged and expired items. Moving forward, all food supplies will be inspected upon delivery by staff, including expiration dates. A copy of the returned/exchanged food items from the food delivery company will be emailed to LPA by the 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.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

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