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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 167209247
Report Date: 08/31/2022
Date Signed: 08/31/2022 11:02:52 AM


Document Has Been Signed on 08/31/2022 11:02 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:ROYAL PARENTS HOME CAREFACILITY NUMBER:
167209247
ADMINISTRATOR:ROY, CHURCHILLFACILITY TYPE:
740
ADDRESS:1980 WEST RIO HONDO WAYTELEPHONE:
(909) 571-9489
CITY:HANFORDSTATE: CAZIP CODE:
93230
CAPACITY:6CENSUS: 0DATE:
08/31/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Roy ChurchillTIME COMPLETED:
11:15 AM
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Licensing Program Analyst(s) (LPAs) K.Kaur and V. Gorban conducted a Pre-licensing Inspection on this date. LPAs met with Administrator Roy Churchill. A tour of the facility was conducted together.

The facility was observed to be at a comfortable temperature, clean, in good repair. No passageway obstructions or fire hazards were observed inside or outside. Common areas were properly furnished and well-lit throughout. The dining room is equipped with a table and chairs, living room is equipped with adequate sofas and chairs for residents, adequate outside space for rest and recreational.

Perishable and non-perishable food supply appeared adequate. Knives will be locked in the kitchen cabinet. Cleaning and Chemical supplies are kept in locked in the laundry room. Residents' bedrooms were observed to be adequately furnished with bed, dresser, and adequate lighting. Mattresses and linen were in good condition. Extra linen and towels are available. Hot water temperature measured at 120 degrees F. Carbon monoxide and smoke alarm detectors installed and operational. Grab bars installed in showers and by toilets, non-skid mats in place, hand soap and paper towels available for use. Trash cans with tight fitting lids are in place. Fire extinguisher was serviced on 8/4/2022 and fully charged. Medications will be locked in the hallway cabinets. First aid kit was observed and had adequate supplies. Complaint poster posted, resident council info posted, residents' rights posted, emergency disaster plan posted. Gate is self-closing and self-latching.

Component III was also conducted and completed. Exit interview was conducted. Pre-licensing requirements were met. An exit interview was conducted with Administrator. Report signed on-site by Administrator and printed copy provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
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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