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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203215
Report Date: 09/15/2021
Date Signed: 09/15/2021 02:47:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:ROYAL CAREFACILITY NUMBER:
107203215
ADMINISTRATOR:RIGON, RUDY G.FACILITY TYPE:
740
ADDRESS:2768 PURVIS AVE.TELEPHONE:
(559) 324-8792
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 2DATE:
09/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Auror Rigon, Assistant AdministratorTIME COMPLETED:
11:35 AM
NARRATIVE
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On 09/15/2021, Licensing Program Analysts (LPA) M. Yang and A. Walton arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPAs introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPAs met with caregiver Modesta Paz. Caregiver call Administrator. Assistant Administrator Aurora Rigon arrived in a short time. LPAs conduct tour with Assistant Administrator . One resident was present during the tour. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. All bathrooms are observed with trash cans with lid and securely fastened grab bars. There are non-skid surfaces in the bathrooms. LPAs observed hand washing posting by all sinks. Bedrooms are single occupant.

LPAs checked residents’ locked medications and observed a 30-day PPE supplies. Food supply was checked and there appeared to be an adequate supply. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. LPAs reviewed 1 out of 2 residents have updated emergency contact information. Facility has not submitted LIC 808 Mitigation plan to CCL. Assistant Administrator agrees to submit LIC 808 to CCL by 9/21/21.

Please submit the requested forms/information to Fresno CCL by: 09/28/21. The following updated forms were requested: LIC 308 Designation of Facility Responsibility, LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan for Residential Care Facilities for The Elderly, LIC 9020 Register of Facility Clients/Residents, updated Liability Insurance, LIC 309 Administrative Organization, current Administrator Certification, current liability insurance, LIC 400 Affidavit Regarding Client/Resident Cash Resources, and LIC 402 Surety Bond.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit interview was conducted and Plan of Correction was reviewed and developed with Assistant Administrator. Due to COVID-19 precautionary measures, a copy of this report and appeal rights will be provided via email and an electronic read receipt confirms receiving this email.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ROYAL CARE
FACILITY NUMBER: 107203215
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPAs observed 1 bottle of Comet under under the laundry sink in the hallway accessible to residents in care, this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2021
Plan of Correction
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The licensee immediately removed the bottle of Comet and placed it in secured cabinet during visit. POC cleared during inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2021
LIC809 (FAS) - (06/04)
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