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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203215
Report Date: 09/08/2022
Date Signed: 09/08/2022 12:30:44 PM


Document Has Been Signed on 09/08/2022 12:30 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, 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: 4DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Aurora Rigon, Assistant AdministratorTIME COMPLETED:
12:35 PM
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On 09/08/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Modesta Paz, Caregiver. Aurora Rigon, Assistant Administrator (AA) was called and arrived shortly and conduct tour with LPA. All four residents were present during the inspection.

Upon entry facility staff was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Social distancing and cough etiquette postings observed.

All resident records reviewed to have updated emergency contact information. LPA observed fire extinguisher served date: 02/18/22. LPA checked residents’ locked medications. LPA observed small amount of PPE supplies in facility. 30 days PPE supplies storage in a central location. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in hall closet.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed four single occupant room. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. Hand washing posting observed by all bathroom sinks. The exterior tour was conducted. Side gate was self-closing and self-latching. Staff records were reviewed for good health and infection control training.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 09/16/22. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 402, Lic 610E, and Lic 9282. LPA received copy of current liability insurance and Lic 500. Administrator was informed that as COVID-19 precautionary measure, this report will be provided via email. Report signed on-site.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
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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