306000688-12-31-2024-22-AS-NGUN-DCGT4V-20241231132434

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306000688
Report Date: 12/31/2024
Date Signed: 12/31/2024 01:25:58 PM

Document Has Been Signed on 12/31/2024 01:25 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ROYAL INN, THE		FACILITY NUMBER:	306000688
ADMINISTRATOR/ DIRECTOR:	ALAN L. SHELLEY		FACILITY TYPE:	740
ADDRESS:	23272 DOWNLAND		TELEPHONE:	(949) 472-9001
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6		CENSUS: 4	DATE:	12/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:40 AM
MET WITH:	Alan Shelley, Madison Shelley,Samantha Dimichina		TIME VISIT/ INSPECTION COMPLETED:	12:55 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Hanna Gough, Nancy Guillen and Licensing Program Manager Sheila Santos made an unannounced visit for the purpose of conducting a required annual Inspection. LPAs were greeted and granted entry by care provider Samantha Dimichina after explaining the purpose of the visit. Administrator (AD) Alan Shelley was notified via telephone and later arrived to assist with the inspection. LPAs observed the Administrator certificate was current and expires March 24, 2025. This is a Residential Care Facility for the Elderly (RCFE) licensed to 6 non-ambulatory residents with a hospice waiver for 4. The facility is a one story home with six resident bedrooms, three bathrooms, and an attached three car garage.

While waiting for the AD, LPAs began review of the records. LPA Guillen reviewed four resident records. All the required documentation were present and current in the residents’ files reviewed. LPA reviewed two employee records. All employee’s present have a criminal record clearance and were associated to the facility. LPAs observed staff records reviewed have a current First Aid certificate.

During the inspection, LPAs and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

LPAs observed residents watching television in the living room and resting in their respective bedrooms. LPAs observed four residents in care and four staff present. LPAs observed the See Something Say Something Poster (PUB 475) mounted on the wall by the garage exit. LPA advised AD to have PUB 475 to be relocated to the entryway of the facility, AD proceeded to place the PUB 475 poster in the entry way of the facility; a technical advisory was given on today’s date. All resident bedrooms had the required furnishings. LPAs observed all resident beds had linens and blankets with additional linens stored in the hallway storage closet. LPAs observed bathrooms were clean and equipped with grab bars and non skid floor mats. LPAs observed all windows were appropriately screened.

Continued on LIC 809-C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Nancy Guillen
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024

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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Document Has Been Signed on 12/31/2024 01:25 PM - It Cannot Be Edited

Created By: Nancy Guillen On 12/31/2024 at 11:43 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROYAL INN, THE	FACILITY NUMBER: 306000688
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(1)(C)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records review, the facility did not comply with the section cited above during the medications review, one out of five of the medications of R4, for medication named PreserVision, did not have a doctor's order on file. This could pose a potential health risk to persons in care if medications are not determine/ prescribed by a physician.
	POC Due Date: 01/07/2025
	Plan of Correction
1 2 3 4	During the visit, the Administrator(AD) was able to get a copy of the prescription from the family. House Manager Madison Shelley will provide in-service medication training to all staff and will provide proof of training to LPA by POC date at the following email address: nancy.guillen@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Armando J Lucero

LICENSING EVALUATOR NAME:

Nancy Guillen

LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROYAL INN, THE	FACILITY NUMBER: 306000688
	VISIT DATE: 12/31/2024

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Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 113.3 and 119.1 degrees Fahrenheit in resident's bathrooms. LPAs toured the outside of the facility and observed outdoor passageways were free of obstruction. LPAs observed the backyard had a shaded sitting area with furniture for resident use.

LPAs observed the facility had a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with a service date of February 29, 2024 and located by the kitchen. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. The garage is used for storage with a portion of the garage converted to a staff room which is kept locked and inaccessible to residents. Toxic chemicals, cleaning solutions, and disinfectants were observed to be locked and inaccessible to residents in the bathroom and under the kitchen sink. Medication cabinet was observed to be locked and centrally stored in the kitchen however, during the medication review, medication named PreserVision was being administered to a resident without a prescription present at the facility; a Deficiency was cited on this date. LPAs observed the First Aid Kit had all the required components. LPAs observed the facility conducted their last emergency disaster drill on October 1, 2024 and is conducted every 3 months.

Based on the observations made during today’s inspection, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was emailed to the Administrator due to a printer error.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Nancy Guillen
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024

LIC809 (FAS) - (06/04)

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