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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609485
Report Date: 03/20/2023
Date Signed: 03/20/2023 12:33:44 PM

Document Has Been Signed on 03/20/2023 12:33 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: 6DATE:
03/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:SLAVA SHCHERBATIME COMPLETED:
12:30 PM
NARRATIVE
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On 3/20/23, Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced pre-license inspection for a change of ownership application. This Case Management-Deficiencies report is to address deficiencies observed during the physical plant tour.

At 11:00 a.m. LPA observed the fire extinguisher to have a service date of 2/15/2022. Additionally, at 11:20 a.m., LPA observed chemicals and cleaning supplies to be accessible to residents in under the bathroom sink.

Deficiencies issued per CA Code of Regulation, Title 22. Report signed and delivered. Appeal rights issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2023
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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Document Has Been Signed on 03/20/2023 12:33 PM - It Cannot Be Edited


Created By: Melissa Ruiz On 03/20/2023 at 12:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2023
Section Cited

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80020(a) Fire Clearance. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement was not met as evidence by:
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Based on observation, the fire extinguisher was last serviced on 2/15/22. The Licensee did not ensure the fire extinguisher was serviced annualy which poses an immediate health and safety risk to residents in care.
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Type A
03/24/2023
Section Cited

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87705(f(2)Care of Persons with Dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Based on observation, licensee failed to ensure that cleaning chemicals were properly stored and inaccessible to residents, which is an immediate health and safety risk to 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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2023


LIC809 (FAS) - (06/04)
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