198601917-1-10-2024-11-AS-WGIS-CZCT2L-20240110132056

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601917
Report Date: 01/10/2024
Date Signed: 01/10/2024 01:21:11 PM

Document Has Been Signed on 01/10/2024 01:21 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	ROYAL ASSISTED LIVING		FACILITY NUMBER:	198601917
ADMINISTRATOR:	SIMLA MEHTA		FACILITY TYPE:	740
ADDRESS:	4925 AVENUE B		TELEPHONE:	(424) 247-8001
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	6	CENSUS: 5	DATE:	01/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Jeniffer Bobadila		TIME COMPLETED:	01:30 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	On 01/10/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. LPA met with Administrator, Jeniffer Bobadila, and explained the purpose of today’s visit. The facility is licensed to operate for six (6) elderly non-ambulatory residents ages 60 and above. The facility is approved for five (5) bedridden and has a hospice wavier for six (6) residents. There are currently five (5) residents residing in the facility. Physical Plant/Structure The facility is a single-story home located in a residential neighborhood. It consists of the following: four (4) resident's rooms, a staff room, four (4) bathrooms, living area, dining area, kitchen and outside covered patio area with a table and chairs. There is an attached garage with access only through the front of the garage and is used for storage. The garage has a washer and dryer for laundry and an additional refrigerator. LPA observed all outside walkways to be clean, clear, and free of obstructions, hazards, and debris. Gates on the side of the home open easily from the inside to exit. LPA did not observe any bodies of water on he premises. Bedrooms LPA inspected all bedrooms and found them to be clean and in good repair. All rooms had the required furniture including bed(s), dresser(s), nightstand(s), chair(s), and ample storage space for resident’s personal belongings. LPA observed beds and bedding supplies were in good repair and an adequate supply was available. All bedrooms were observed with ample lighting. Bathrooms LPA inspected all bathrooms and found them to be to be within Title 22 regulations and were clean and operational. All safety handrails were secured. LPA observed showers with nonskid mats and a shower chair. The water temperature measured between 114.6-degrees and 119.3-degrees Fahrenheit. LPA observed an ample supply of towels and hygiene products for residents. Kitchen LPA inspected the kitchen and found it to be clean and sanitary. LPA observed an ample supple of cookware, dining ware, and cutleries in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. LPA observed all knives and sharps secured in a locked drawer in the kitchen. LPA observed cleaning supplies secured in a locked cabinet in the kitchen under the sink and are inaccessibly to residents. The water temperature in the kitchen measured 115.9-degrees Fahrenheit.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ROYAL ASSISTED LIVING	FACILITY NUMBER: 198601917
	VISIT DATE: 01/10/2024

NARRATIVE

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Common Room All rooms were observed to be sanitary and appropriately furnished at the time of visit. All inside walkways and hallways were observed clean, clear, and free of obstructions or hazards. A comfortable temperature was maintained in the facility. All rooms had ample lighting. LPA observed a fireplace in the living room that is screened and inaccessible to residents.
Medications LPA observed all centrally stored medication secured in a locked cabinet in the kitchen and are inaccessible to residents. Medications were observed in their original containers. LPA reviewed the medication for four (4) residents and found them to be consistent with the Medication Administration Record (MAR).
File Review & Interviews LPA reviewed three (3) resident files and found they contained the required documents. During interviews, residents stated they are happy with the services they receive at the facility. LPA reviewed the administrator file and three (3) staff files and found they contained the required document, training, and certifications. LPA interviewed two (2) Direct Support Professionals that answered questions regarding resident care, rights, and policies. LPA observed all mandated signs posted throughout the facility. LPA reviewed and received a copy of the facility Liability Insurance through James River Insurance Company and is valid till 05/16/24.
Safety LPA observed a fully charged fire extinguisher, in the dining room, last serviced on 01/02/24. The last emergency drill was conducted on 01/08/24. The last Fire Alarm and Signaling Inspection 02/25/23. The last Fire Prevention Inspection by the Torrance Fire Department was last conducted on 02/25/23. Smoke detectors and carbon monoxide detectors were observed operable. The First Aid Kit was observed to contain the required items and a manual. When doors leading outside are opened, there is an indicator that informs staff a door has been opened.
Infection Control Upon entry, LPA observed a sanitizing station and visitor sign in log. LPA observed sanitizing stations throughout the facility. LPA observed infection control signs posted throughout the facility. LPA observed a 90-day supply of Personal Protective Equipment (PPE) stored in a closet.

During today's visit, LPA did not observe or cite any deficiencies.

An exit interview was conducted with Administrator, Jeniffer Bobadilla, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC809 (FAS) - (06/04)

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