197610363-5-18-2024-31-AS-CDCN-D5DQQ6-20240518122150

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610363
Report Date: 05/18/2024
Date Signed: 05/18/2024 12:22:23 PM

Document Has Been Signed on 05/18/2024 12:22 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
Lookup Error,
, CA

FACILITY NAME:	AAA ROYAL SENIOR LIVING FACILITY		FACILITY NUMBER:	197610363
ADMINISTRATOR:	KRISTINA ADMAYAN		FACILITY TYPE:	740
ADDRESS:	6214 BECKFORD AVE		TELEPHONE:	(818) 609-0117
CITY:	TARZANA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 6	DATE:	05/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Vanisa Campbell, Staff		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection. LPA met with Staff, Vanisa Campbell, and explained the purpose of the visit. Licensee/Administrator, Kristina Adamyan, arrived shortly after to assist with the visit. The facility is licensed for 6 non-ambulatory residents, ages 60 and over, of which 1 may be bedridden. Bedroom #3 is approved for bedridden. Facility has a hospice waiver approved for 5 residents. LPA conducted the inspection using the Compliance and Regulatory Enforcement (CARE) Tools. The following were observed: Infection Control: The facility has an Infection Control Plan posted. Staff are continuing to clean and disinfect the home daily. They are wearing gloves while assisting residents. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are no residents utilizing oxygen at this time. Physical Plant & Environment Safety: The facility consists of 4 resident rooms, 2 bathrooms, staff office area, living room, dining room, kitchen, and detached garage. The backyard has a shaded area for resident use. There are no swimming pool or bodies of water on the premises. The facility has a carbon monoxide detector located in the hallway near the kitchen. There are no items obstruction the hallways or ramps. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator. Staffing: All staff members have current CPR & First Aid certificates. Per the licensee, there is sufficient staffing and has backup staffing if needed. Personnel Records-Training: LPA reviewed 3 personnel files. The administrator's (Kristina Adamyan) certificate expires on 12/28/26. Staff have fingerprint clearance and associated to the facility. Staff files have the required documents such as personnel record, health screening with TB results, employee rights form, and in-service training. Staff also have sufficient number of training hours for dementia care.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: 323-981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2024

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
Lookup Error,
, CA

FACILITY NAME: AAA ROYAL SENIOR LIVING FACILITY	FACILITY NUMBER: 197610363
	VISIT DATE: 05/18/2024

NARRATIVE

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Resident Records-Incident Reports: LPA reviewed 6 resident files that are maintained at the facility. The files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, preappraisal form, and personal rights form.
Resident Rights-Information: Information for appropriate reporting agencies are posted at the facility. Residents' rights are respected and implemented by staff.
Planned Activities: Facility has sufficient space to provide indoor and outdoor activities to accommodate residents who are physically handicapped.
Incidental Medical and Dental: LPA reviewed 6 resident medications and there were no discrepancies observed. Resident using insulin injections can self administer the medication.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Emergency procedures are indicated on the form.
Residents with Special Health Needs: Facility accepts and retains residents with dementia. Staff are ensuring that incontinence residents are changed often and the facility remains free of odor from incontinence. There are currently 2 residents receiving hospice services. There are no residents with prohibited health conditions.

There are no deficiencies observed today. An exit interview was held. A copy of this report along with appeal rights are given to the licensee.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: 323-981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2024

LIC809 (FAS) - (06/04)

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