306000688-12-22-2025-22-AS-BLOZ-DPLVYQ-20251222155130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306000688
Report Date: 12/22/2025
Date Signed: 12/22/2025 03:52:09 PM

Document Has Been Signed on 12/22/2025 03:52 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: 6	DATE:	12/22/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Licensee Alan Shelley and House Manager Madison Shelley		TIME VISIT/ INSPECTION COMPLETED:	04:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On December 22, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. House Manager (HM) Madison Shelley was present, and Licensee (LI) Alan Shelley later arrived to assist with the inspection. LPA observed that Alan Shelley has a valid Administrator certificate which expires on March 24, 2027. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents and has a hospice waiver for four. The facility is a one story home with six private resident bedrooms, three shared resident bathrooms, a living room, a dining room, a kitchen, and an attached two car garage. LPA, accompanied by the HM, conducted a tour of the interior portions of the facility. On today's visit, there were six residents in care and two care giving staff present. LPA observed the resident relaxing in the living room and in their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected all six resident bedrooms and they were observed to be free of any hazards. LPA observed the resident bedrooms had all the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds had clean linens and blankets. LPA observed additional linens and blankets are stored in a hallway closet. LPA inspected the three shared resident bathrooms. Resident bathrooms are clean. Resident bathrooms were equipped with grab bars and nonskid floor mats. Faucets and toilets were operational. Hot water temperature measured between 112.2 and 117.6 degrees Fahrenheit. LPA observed that the kitchen has a two day perishable and a seven day nonperishable food supply on hand. Kitchen appliances were clean and operational. LPA observed the five burner gas stove lights unassisted. CONTINUED ON LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 12/22/2025

NARRATIVE

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LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet. LPA observed toxins and chemicals to be stored in a locked kitchen cabinet under the sink. A fire extinguisher is located in the kitchen and it was observed to be charged and purchased on November 29, 2025. LPA tested the individual smoke detectors and carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on December 20, 2025. The centrally stored medication is kept in a locked cabinet located in the kitchen. LPA observed a First Aid Kit to be stored in the kitchen and it had all the required components. LPA observed the door leading to the attached two car garage to kept locked and inaccessible to residents in care. LPA observed the garage to be used for storage. LPA observed the facility has a three day emergency food and water supply stored in the garage.

LPA, accompanied by the HM, conduct a tour of the exterior portion of the facility. LPA observed the exterior portion of the facility to be free of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gates of the facility are self-latching and can be open in an evacuation. There are no bodies of water on the premises.

LPA reviewed all six resident files. LPA observed that there was no Medical Assessment on file for Resident #5 (R5). LPA reviewed the residents' medication and medication administration record. LPA reviewed five staff files. All staff are background cleared and associated to the facility.

Based on the observations made during today's visit, one deficiency is being cited on the attached LIC809-D. An exit interview was conducted with House Manager Madison Shelley. A copy of the report and Appeal Rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/22/2025 03:52 PM - It Cannot Be Edited

Created By: Brandon Lopez On 12/22/2025 at 03:42 PM

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: 12/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that there was no Medical Assessment on file for Resident #5 (R5).
	POC Due Date: 01/19/2026
	Plan of Correction
1 2 3 4	The House Manager stated that she will obtain a Medical Assessment for R5. The House Manager agreed to provide the Medical Assessment for R5 to LPA via email or fax by POC date.

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.

	Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:

	Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025

LIC809 (FAS) - (06/04)

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