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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203215
Report Date: 08/30/2024
Date Signed: 09/05/2024 10:49:04 AM


Document Has Been Signed on 09/05/2024 10:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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:
08/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator-Rudy RigonTIME COMPLETED:
03:00 PM
NARRATIVE
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On 08/30/24 Licensing Program Analysts (LPA) J. Leffall and M. Yang arrived unannounced to conduct an Annual Inspection. LPAs introduced selves, stated the purpose of the visit, and was greeted by Staff (S1) Modesta Paz and Danica Campos Staff 2 (S2). LPAs was granted entry. 1 resident was present during inspection. Licensee Aurora Rigon (L1) was called and arrived shortly after LPAs arrival.

LPAs toured facility with A1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at 0 degrees F and refrigerator temperature was maintained at 36.2 degrees F. Medications were checked and observed kept locked in the kitchen cabinet. Residents’ MARS was reviewed. Fire extinguisher was observed with a purchase date of: 02/13/24.

Carbon monoxide and smoke detectors were tested and observed to be operational. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a temperature of 107.4 in resident bathroom 1, 105.2 in hall bathroom, and 105.2 and 105 degrees F. in master bathroom. Non-skid mat and grab bars observed in bathrooms. Gardening tools and chemicals observed unlock in the garage. A chemical bottle observed unlock in laundry shelf. Outside of facility toured. Side gate was self-closing. Outside was observed with adequate outdoor seatings available for residents. First-aid kit observed with all of the required items. Sample of staff and resident files were reviewed.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22,Division 6. Exit interview was conducted.The following documents requested to be updated and submitted to Fresno CCL by 09/5/24: Lic 308, Lic 500, Lic 610E, Current Liability Insurance and current Administrator’s certificate. A copy of this report and appeal rights was provided to Designee, whose signature on this form confirms receipt of these report.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Jacques LeffallTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
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


Document Has Been Signed on 09/05/2024 10:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: ROYAL CARE
FACILITY NUMBER: 107203215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
87465(c)(2)
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation resident 1 (R1) medication was checked and MARs was reviewed. Two out of six medications were not administered as directed by staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2024
Plan of Correction
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Licensee agrees to have all staff retrained in Medication training and submit written documentation upon completion of training. Proof of staff trainings and rooster of staff attendance will be submitted to the Fresno CCL by POC due date 08/31/24.
Type A
Section Cited
CCR
87309(a)
87309(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 and Administrator observed knives unlock in kitchen drawer, cleaning chemicals unlock in laundry shelf and in garage cabinet accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2024
Plan of Correction
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Administrator immediately locked chemicals in hall closet and locked the knife drawer. Gardening tools was immediately removed out of the facility. POC cleared.
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: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Jacques LeffallTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/05/2024 10:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: ROYAL CARE
FACILITY NUMBER: 107203215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place... not accessible to persons other than employees...

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 and Administrator observed refrigerate medications stored unlocked in the small black refrigerator accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2024
Plan of Correction
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Administrator immediately removed medications to locked area. POC cleared during visit.
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: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Jacques LeffallTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3