197610443-9-22-2023-31-AS-MSPH-CVWKLT-20230922080025

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610443
Report Date: 09/21/2023
Date Signed: 09/22/2023 08:00:32 AM

Document Has Been Signed on 09/22/2023 08:00 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ROYAL LAKE VIEW LLC		FACILITY NUMBER:	197610443
ADMINISTRATOR:	HOVANNESYAN, NAREK		FACILITY TYPE:	740
ADDRESS:	35940 TIERRA SUBIDA AVE		TELEPHONE:	(818) 426-8821
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 0	DATE:	09/21/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Narek Hovannesyan		TIME COMPLETED:	01:00 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	On 9/21/2023, Licensing Program Analyst (LPA) Melissa Spaeth conducted an announced Pre-Licensing visit to this facility and met with the Licensee. This is a new application and a fire clearance dated 8/08/2023 was received for four non-ambulatory residents and one non-ambulatory bedridden resident. The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6. Today’s site visit consisted of LPA touring the physical plant inside and outside from 9:15 am until 10:45 am. LPA Spaeth observed the following: Living/Dining Room – LPA observed the living room and dining room are combined. The living room area consists of comfortable seating. The dining room contained a dining room table with chairs. LPA observed a wood stove insertion within a lower level fireplace. The area was surrounded by a metal fencing that was locked. Kitchen - The facility contained a seven day supply of non-perishable food and a two day supply of perishable foods. A locked kitchen cabinet contained resident medication containers and the first aid kit. There is a locked drawer for knives. A fire extinguisher is also located in the kitchen. Appliances in the kitchen appeared to be functional. Backyard - The backyard is a two level area which consists of a upper and lower area. The upper area is a shaded area which contains comfortable seating. The lower area is surrounded by a locked gated area in order to ensure the safety of the residents. The side gate leading from the backyard to the front yard was not locked. Continued - 809C

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYAL LAKE VIEW LLC	FACILITY NUMBER: 197610443
	VISIT DATE: 09/21/2023

NARRATIVE

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Bedrooms - There are four bedrooms (Room 2, 3, 4, and 5) which contained bed, linens, night stand, lamp, chest of drawers, and a chair.

Office – Room 1 is for staff use only and contained a desk.

Bathrooms- There are three bathrooms which contained hand soap, paper towels, trash can, grab bars, and slip resistant mats. LPA Spaeth tested the water temperature in two bathrooms at 9:48 am and 10:15 am. The recordings were 105.0 degrees F and 110 degrees F.

Garage- LPA observed four locked metal storage closets which contained additional hygiene items, non-perishable and emergency food items, and cleaning solutions. The washer and dryer are located in the garage.

The smoke and carbon monoxide detectors were tested at 10:45 am and were operable. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all exit doors. The facility was clean and appears to be in good repair.

Component III was conducted with the applicant from 11:00 am until 11:45 am.

This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. Exit interview was conducted with Licensee. A copy of this report was signed and delivered.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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