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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609001
Report Date: 06/03/2022
Date Signed: 06/03/2022 01:24:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2022 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220601123035
FACILITY NAME:ROYALTY ASSISTED LIVINGFACILITY NUMBER:
197609001
ADMINISTRATOR:AVETIAN, LIDUSHFACILITY TYPE:
740
ADDRESS:10940 STRATHERN STREETTELEPHONE:
(818) 436-9088
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY:10CENSUS: 13DATE:
06/03/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Estella AvetyanTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility is operating beyond the terms and conditions of the license
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegation above. LPA met with facility staff and explained the reason for this visit.
It is alleged that the facility now has thirteen residents which is three over the capacity of ten residents the facility is allowed to have. LPA conducted a physical plant tour at approximately 10:40-10:50am. LPA observed there to be seven bedrooms with thirteen residents. Upon entry to the facility staff when asked how many residents they had stated they had thirteen residents at the facility. Staff stated five residents came from facility named ROYALTY ASSISTED LIVING II, 197609666 which the owner of this facility also owns. Staff stated that ROYALTY ASSISTED LIVING II was going to close and that's why the residents were brought to this facility. Based on the information obtained through observation and interview this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D. Exit Interview conducted.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 31-AS-20220601123035
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYALTY ASSISTED LIVING
FACILITY NUMBER: 197609001
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2022
Section Cited
CCR
87204(A)
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Limitations-Capacity and Ambulatory Status-A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. This requirement is not met as evidenced by:
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Administrator stated that three of the residents will be relocated by plan of correction due date and will submit a capacity increase by next week.
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Based on observation and interviews facility has thirteen residents which is more than the ten residents the facility is licensed for which poses an immediate health and safety issue for all residents 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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC9099 (FAS) - (06/04)
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