197609001-11-15-2023-31-AS-CALH-CXLVXN-20231115154948

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609001
Report Date: 11/15/2023
Date Signed: 11/15/2023 03:50:42 PM

Document Has Been Signed on 11/15/2023 03:50 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ROYALTY ASSISTED LIVING		FACILITY NUMBER:	197609001
ADMINISTRATOR:	AVETIAN, LIDUSH		FACILITY TYPE:	740
ADDRESS:	10940 STRATHERN STREET		TELEPHONE:	(818) 436-9088
CITY:	SUN VALLEY	STATE: CA	ZIP CODE:	91352
CAPACITY:	10	CENSUS: 9	DATE:	11/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Karine Charchoghlyan		TIME COMPLETED:	04:00 PM

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On 11/15/2023 at 8:30 AM, Licensing Program Analyst (LPA) Christopher Alemoh conducted an unannounced Required – Annual Continuation Inspection and met with Karine Charchoghlyan, Caregiver. LPA contacted Administrator Lidush A. she was unavailable due to a doctors appt. LPA continued visit with designee Karine .C. Seven (7) residents and two (2) staff were present during this inspection. The home consists of 1 floor level with: 1 staff room, 6 resident rooms, 2 restrooms, kitchen, dining room, and laundry room.

The administrator accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. All windows have screens.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between. Facility has two (2) restrooms both located in the middle hallway. LPA observed Restroom #1 temp measured at 106.2-107F. Restroom #2 temp measured at 108F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. hand washing signs posted and visible.

Laundry Room is in an alcove in the middle hallway both washer and dryer are in good working order. All chemicals and solutions are stored above the appliances locked and secured in a cabinet.

Common areas were clean and clear of hazards, doorways were free of obstructions.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Christopher Alemoh	TELEPHONE: 818-669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYALTY ASSISTED LIVING	FACILITY NUMBER: 197609001
	VISIT DATE: 11/15/2023

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(Contd From 809)

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher was observed in the kitchen area. A second fire extinguisher is located near the entryway by the front door. Both extinguishers were serviced on. LPA tested all carbon monoxide detectors and smoke detector located in the kitchen area. Both devices were functional. LPA observed that all bedrooms and hallways are equipped with a carbon monoxide and smoke detector.

Four (4) staff records were reviewed, 4 out of 4 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions.

Nine (9) resident records were reviewed and, 9 out of 9 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans.

An exit interview was conducted, Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Caregiver Karine Charchoghlyan.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Christopher Alemoh	TELEPHONE: 818-669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC809 (FAS) - (06/04)

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