197610363-3-20-2023-31-AS-MRUZ-CQ4QHQ-20230320121130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610363
Report Date: 03/20/2023
Date Signed: 03/20/2023 12:14:02 PM

Document Has Been Signed on 03/20/2023 12:14 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 FACILITY		FACILITY NUMBER:	197610363
ADMINISTRATOR:	SHCHERBA, SLAVA		FACILITY TYPE:	740
ADDRESS:	6214 BECKFORD AVE		TELEPHONE:	(818) 609-0117
CITY:	TARZANA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 6	DATE:	03/20/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Slava Shcherba - Administrator		TIME COMPLETED:	12:20 PM

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On 3/20/2023, Licensing Program Analysts (LPA) Melissa Ruiz conducted an unannounced Pre-License visit to this facility and met with Administrator Slava Shcherba. This is a Change of Ownership Application from facility license number #197609485 to #197610363. A fire Clearance dated 11/15/2022 was received for six (6) residents, of which five (5) could be non-ambulatory residents, and one (1) bedridden in room #3. Facility has a hospice waiver for four (4) residents. The purpose of today’s visit is to inspect the facility to ensure compliance, under California Code of Regulations, Title 22, Division 6.

At 11:15 a.m., LPA conducted a physical plant tour inside and outside and observed the following:

The facility has separate carbon monoxide and smoke alarm system. At 11:00 a.m., fire extinguisher was observed to be expired. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements.

There are (4) resident bedrooms, two of which are (2) private and two (2) are shared. Resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen, and dining areas) were appropriately furnished, and lighting was adequate. The living room has a television and comfortable furniture. Resident and staff records are stored in a locked cabinet in the designated office area. Medications are centrally stored and locked. The first aid kit is readily available. There are two (2) bathrooms and at 11:20 a.m., chemicals and cleaning supplies were observed to be accessible to residents in care. Trash cans were not observed to have closed tight fitting lids.

(cont, LIC809-C)

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
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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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: 197610363
	VISIT DATE: 03/20/2023

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The kitchen knives are stored in a locked cabinet. The kitchen cleaning supplies are stored in a locked cabinet under the kitchen sink. The laundry area is outside. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced. The garage is attached to the house and is kept locked and inaccessible to residents. The garage is currently being used as a laundry area, emergency and perishable food and other supplies storage such as PPE. There is no body of water in the facility.

Deficiencies issued under facility #197609485. This report will be forwarded to the Centralized Application Bureau (CAB). Contingent upon completion of the following, you will be notified by the CAB Analyst when your license has been approved.

The licensee shall provide the following no later than 3/31/2023:

· New fire extinguisher that is fully charged

· Photos showing new locks have been placed in the kitchen and bathroom cabinets

· Trash cans with lids for all trash cans

· Receipt and pictures of emergency food supply

Exit interview was conducted with Administrator Slava Shcherba. A copy of this report was signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
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

LIC809 (FAS) - (06/04)

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