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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601566
Report Date: 07/27/2023
Date Signed: 08/08/2023 12:40:47 PM


Document Has Been Signed on 08/08/2023 12:40 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:STUDIO ROYALEFACILITY NUMBER:
198601566
ADMINISTRATOR:TERRI WEITZMANFACILITY TYPE:
740
ADDRESS:3975 OVERLAND AVENUETELEPHONE:
(310) 836-5854
CITY:CULVER CITYSTATE: CAZIP CODE:
90232
CAPACITY:175CENSUS: 89DATE:
07/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:EJ Lewis & Kelly Metz TIME COMPLETED:
01:49 PM
NARRATIVE
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On 07/27/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management inspection visit at this facility. LPA met with the Vice President of Operations Kelly Metz and Executive Director EJ Lewis and explained the purpose of the visit is in association with complaint 11-AS-20230726113120.

During a case management inspection visit on 07/27/23, The Department observed resident #1 (R1's) AC system was in disrepair. Interviews with staff #1-#2 (S1-S2) reported they did not report to Community Care Licensing (CCL) that the AC system for (R1's) room was in disrepair. (S1) stated no relocation offer was made to (R1), only to the roommate resident #2 (R2) who refused the offer. According to (R2), he wasn't offered to relocate and disputed (S1)'s claims.

The licensee violates Title 22 Regulations 87211 Reporting Requirements and 87468.1 Personal Rights of Residents in All Facilities. California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 9099-D).

An exit interview is conducted with EJ Lewis and a copy of the report is provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
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 08/08/2023 12:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: STUDIO ROYALE
FACILITY NUMBER: 198601566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2023
Section Cited
CCR
87211(a)(d)

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87211 Reporting Requirements - (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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The licensee will adhere to Title 22 Section 87211. Plan of correction is for Licensee to submit a LIC 629 Incident Report POC due: 08/03/23 of the incident associated with (R1).
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This requirement was not met as evidenced by: Based on observation and interview, the licensee failed to report the disrepair AC for (R1's) apartment to CCLD. This citation poses a potential health and safety risk to residents in care.

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Type B
08/03/2023
Section Cited
CCR87465.1(a)(2)

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87465.2 Personal Rights of Resident in all Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment
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The licensee will adhere to Title 22 Section 87465. Plan of correction is to submit to review the regulation and a plan to meet a safe, healthful accomodations for (R1-R2). POC will need to be submitted by 08/03/23.

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This requirement was not met as evidenced by: Based on observation and interview, failed to provide a safe and comfortable accomodations to (R1) & (R2). This citation poses a potential 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
LIC809 (FAS) - (06/04)
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