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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610432
Report Date: 06/19/2023
Date Signed: 06/19/2023 11:27:14 AM

Document Has Been Signed on 06/19/2023 11:27 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:HOLLYWOOD ROYALE GARDEN ASSISTED LIVINGFACILITY NUMBER:
197610432
ADMINISTRATOR:JOGANI, PINKALFACILITY TYPE:
740
ADDRESS:6054 FRANKLIN AVE.TELEPHONE:
(323) 466-2411
CITY:LOS ANGELESSTATE: CAZIP CODE:
90028
CAPACITY: 120CENSUS: DATE:
06/19/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:JOSE MARQUES
PINKAL JOGANI		TIME COMPLETED:
11:30 AM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 120
Census (if any clients in care): ELDERLY
COMP II Participants: PINKAL JOGANI/APPLICANT AND JOSE MARQUEZ ADMINISTRATOR
Interview Method: Telephone interview

On 6/19/23, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
SUPERVISORS NAME: Mirella Quaranta
LICENSING EVALUATOR NAME: Stefania Fonteno
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
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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