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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609485
Report Date: 10/20/2022
Date Signed: 10/20/2022 01:19:51 PM


Document Has Been Signed on 10/20/2022 01:19 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:AAA ROYAL SENIOR LIVING FACILITYFACILITY NUMBER:
197609485
ADMINISTRATOR:SHCHERBA,VIACHESLAVFACILITY TYPE:
740
ADDRESS:6214 BECKFORD AVETELEPHONE:
(818) 609-0117
CITY:TARZANASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 5DATE:
10/20/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Slava ScherbaTIME COMPLETED:
01:25 PM
NARRATIVE
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At 12:40 p.m. on 10/20/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an announced Plan of Correction visit. LPA met with Administrator and disclosed the reason for the visit.

At 12:45 p.m. LPA measured the water temperature in the shared bathroom to be 126. 2 degrees Fahrenheit

At 12:52 p.m. LPA measured the water temperature in the private bathroom to be 127.3 degrees Fahrenheit. The deficiency has not been corrected by the Plan of Correction due date

Exit interview conducted. Copy of report and appeal rights provided. Citation issued on LIC 809-D page.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
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 10/20/2022 01:19 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, 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: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2022
Section Cited

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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... not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
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Based on observations the licensee did not comply with the section cited above in 2 out of 2 bathroom faucets which posed an immeidate Health, Safety, or Personal Rights risk to persons 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: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
LIC809 (FAS) - (06/04)
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