<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600577
Report Date: 06/11/2024
Date Signed: 06/11/2024 05:01:10 PM


Document Has Been Signed on 06/11/2024 05:01 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:MORAGA ROYALEFACILITY NUMBER:
075600577
ADMINISTRATOR:RICKMAN, FAILELOTO TFACILITY TYPE:
740
ADDRESS:1600 CANYON ROADTELEPHONE:
(925) 376-8900
CITY:MORAGASTATE: CAZIP CODE:
94556
CAPACITY:120CENSUS: 78DATE:
06/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Faileloto Richman, AdministratorTIME COMPLETED:
05:30 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 06/11/24 at approximately 1:00PM LPAs K. Nguyen and G. Luke arrived unannounced at the above location to conduct a required annual inspection. Upon arrival, LPAs met with Rickman and explained to her the reason for the visit.

LPAs inspected the following but not limited to areas to include common living spaces, dining room, kitchen, shared restrooms, reception, activity room, outdoor spaces and random resident rooms and bathrooms. LPAs measured and observed the hot water temperature in random resident bathrooms on the 1st and 2nd Floors at 107.5 degrees Fahrenheit. LPAs observed that the facility temperature was 76 degrees Fahrenheit via thermostat.

Facility has an 7 day supply of non-perishables and a 2 day supply of perishables. The fire extinguishers appeared fully charged last inspected on 5/28/2024. The memory care unit was inspected and found to be equipped with delayed egress. The facility has interconnected pull-type fire alarms and sprinklers throughout. Smoke detectors and carbon monoxide detectors were observed throughout the facility. All required posters were found posted and visible in the facility. Medications were observed locked and centrally stored in medication rooms and locked medication carts. First aid kit was complete with manual. Facility has a disaster plan and the last disaster drill was conducted on 04/29/2024. LPAs conducted a review of resident and staff records.

Report continue in LIC 809C…

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MORAGA ROYALE
FACILITY NUMBER: 075600577
VISIT DATE: 06/11/2024
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
26
27
28
29
30
31
32
Deficiency was observed:

At 2:15pm LPAs observed S5 is not fingerprint clear on guardian. Civil Penalty of $500 is being assessed.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview was conducted. A copy of this report, civil penalty ,and appeal rights provided via email.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3