198601917-1-10-2025-11-AS-WGIS-DCSS49-20250110123223

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601917
Report Date: 01/10/2025
Date Signed: 01/10/2025 12:32:35 PM

Document Has Been Signed on 01/10/2025 12:32 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/ DIRECTOR:	SIMLA MEHTA		FACILITY TYPE:	740
ADDRESS:	4925 AVENUE B		TELEPHONE:	(424) 247-8001
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	01/10/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Charesa Reyes		TIME VISIT/ INSPECTION 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	On 01/10/25, the department conducted an unannounced annual visit to the facility listed above. The department met with Administrator Designee, Charesa Reyes, 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 six (6) 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. The department 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. The department did not observe any bodies of water on he premises. Bedrooms The department inspected all bedrooms and found them to be clean and in good repair. All rooms had the required furniture including bed(s), dresser(s), (1) Continued on LIC809-C

Eva M Alvarez	TELEPHONE: (323) 981-1755
Wendy Gibbs	TELEPHONE: (323) 981-1755
	DATE: 01/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

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: 01/10/2025

NARRATIVE

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nightstand(s), chair(s), and ample storage space for resident’s personal belongings. The department observed beds have the required linens including a mattress cover, fitted sheets, blankets, comforter, and pillows. The department observed beds and bedding supplies were in good repair and an adequate supply was available. All bedrooms were observed with ample lighting.
Bathrooms The department inspected all bathrooms and found them to be to be within Title 22 regulations and were clean and operational. All safety handrails were secured. The department observed showers with nonskid mats and a shower chair. The water temperature measured between 114.4-degrees and 119.4-degrees Fahrenheit. The department observed an ample supply of towels and hygiene products for residents.
Kitchen The department inspected the kitchen and found it to be clean and sanitary. The department observed an ample supple of cookware, dining ware, and cutleries in good repair. The department observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods properly packaged and labeled. The department observed all knives and sharps secured in a locked drawer in the kitchen. The department observed cleaning supplies secured in a locked cabinet in the kitchen under the sink. The water temperature in the kitchen measured 116.9-degrees Fahrenheit.
Common Areas All rooms were observed to be sanitary and appropriately furnished at the time of visit. The dining room has a large table and chairs to accommodate all residents. The department observed games and activities in a

(2) CONTINUED ON LIC809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

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: 01/10/2025

NARRATIVE

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cabinet in the dining room available for Resident use. The living room has two (2) couches and two (2) recliners to accommodate residents. The department observed a fireplace in the living room that is screened and inaccessible to residents. All inside walkways and hallways were observed clean, clear, and free of obstructions or hazards. A comfortable temperature was maintained in the facility.
Medications The department 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. The department reviewed the medications for four (4) residents and found them to be consistent with physician’s orders and centrally stored medications list.
File Review The department reviewed six (6) resident files and found they contained the required documents. The department reviewed the administrator file and five (5) staff files and found they contained the required documents, training, and certifications. LPA observed all mandated signs posted throughout the facility. The department reviewed and received a copy of the facility Liability Insurance through Acord and is valid till 05/16/25. The department observed licensing fees are current.
Safety The department observed a fully charged fire extinguisher, in the dining room, last serviced on 01/03/25. The last emergency drill was conducted on 01/01/25. The last Fire Alarm and Signaling Inspection 01/03/25. The last Fire Prevention Inspection by the Torrance Fire Department was last conducted on
(3) CONTINUED ON LIC809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

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: 01/10/2025

NARRATIVE

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01/03/25. Smoke detectors and carbon monoxide detectors were observed operable. The First Aid Kit was observed to contain the required items and a current manual. When doors leading outside are opened, there is an indicator that informs staff a door has been opened. The facility has a working landline telephone.
Infection Control Upon entry, the department observed a sanitizing station and visitor sign in log. The sanitizing station has masks and gloves available. The department observed sanitizing stations throughout the facility. The department observed infection control signs posted throughout the facility. The department observed a 90-day supply of Personal Protective Equipment (PPE) stored in a closet.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the department did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was conducted with Administrator Designee, Charesa Reyes and a copy of this report was provided.

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SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

LIC809 (FAS) - (06/04)

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