197609485-10-13-2022-31-AS-NRED-CK6PY9-20221013114335

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609485
Report Date: 10/13/2022
Date Signed: 10/13/2022 11:44:08 AM

Document Has Been Signed on 10/13/2022 11:44 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	AAA ROYAL SENIOR LIVING FACILITY		FACILITY NUMBER:	197609485
ADMINISTRATOR:	SHCHERBA,VIACHESLAV		FACILITY TYPE:	740
ADDRESS:	6214 BECKFORD AVE		TELEPHONE:	(818) 609-0117
CITY:	TARZANA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 5	DATE:	10/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Slava Scherba		TIME COMPLETED:	10:00 AM

NARRATIVE

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At approximately 8:45 a.m. on 10/13/2022 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and disclosed the reason for the visit. LPA toured the facility inside and out.

The facility was last visited on 10/14/2021 for an annual visit. It is a single story building with 4 bedrooms, 2 bathrooms, kitchen, garage, office, common areas, and outdoor areas. It has an approved fire clearance for 5 nonambulatory residents, of which 1 may be bedridden in Bedroom #3. Approved hospice waivers for 4.

Upon entry, LPA observed a maintained front yard. A ramp in good condition with sturdy hand rails led to the main entrance. A sign for the facility’s masking policy was posted on the front door. Additional postings inside included the facility license, Administrator certificate, Emergency Disaster Plan, COVID precautions, personal rights, confidential complaint contacts, ombudsman contacts, house rules, and facility sketch. LPA was not screened for infectious disease upon entry. The screening station contained hand sanitizer, digital thermometer, surgical masks, and a visitor log. LPA observed a fully-charged fire extinguisher in the living room.

The facility had 4 bedrooms. Bedroom #1 and Bedroom #4 were private. Bedroom #2 and Bedroom #3 were shared. The window screen in Bedroom #1 was detached. Staff explained that the facility is currently under renovation. At approximately 9:10 a.m., LPA also observed 4 medications and 1 syringe accessible by the bed side. A deficiency for accessible medication is cited on the LIC 809-D page. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding.

The facility had 2 bathrooms. All bathrooms contained liquid soap, grab bars near the toilet and shower, and a non-skid mat in the shower. At 9:19 a.m. LPA measured the water temperature in the shared bathroom to be 147.1 degrees Fahrenheit. A deficiency for water temperature was cited on the LIC 809-D page.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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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Document Has Been Signed on 10/13/2022 11:44 AM - 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AAA ROYAL SENIOR LIVING FACILITY	FACILITY NUMBER: 197609485
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 2 bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/20/2022
	Plan of Correction
1 2 3 4	Licensee to adjust hot water temperature and provide proof of correction to LPA by POC due date.

Type A

Section Cited

CCR

87465(h)(2)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 4 medications which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2022
	Plan of Correction
1 2 3 4	Medications were locked and made inaccessible during visit. POC cleared.

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 Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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

FACILITY NAME: AAA ROYAL SENIOR LIVING FACILITY	FACILITY NUMBER: 197609485
	VISIT DATE: 10/13/2022

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Walls, floors, and ceilings were clean and in good repair. At 9:20 a.m. LPA measured the room temperature to be 75 degrees Fahrenheit. LPA observed an adequate supply of perishable and non-perishable food. Kitchen surfaces were sanitary and appliances were functional. LPA observed locks on 2 out of 2 refrigerators. The Administrator stated the lock will be removed from the kitchen refrigerator. Sharps were locked above the counter top, and cleaning solutions were locked below the sink. LPA observed staff using an operable washer and dryer in the rear of the facility. Outdoor space was maintained. The rear exit was unlocked with a pad lock hanging from a latch. The Administrator proposed that the key will be maintained in the pad lock for nighttime safety and emergency safety.

At 9:47 a.m. LPA tested the dual functioning smoke and carbon monoxide detector to be operational. 3 out of 3 detectors functioned simultaneously. Auditory alarms were on and functioning. A fully stocked first aid kit and locked medications were located near the office area.

During today's inspection, the facility was not in compliance with Title 22 regulations. Exit interview conducted. Copy of report, appeal rights, and deficiencies issued.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC809 (FAS) - (06/04)

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