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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003567
Report Date: 12/08/2022
Date Signed: 12/08/2022 04:38:43 PM

Document Has Been Signed on 12/08/2022 04:38 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 & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:STATE ROYALE GUEST HOMEFACILITY NUMBER:
306003567
ADMINISTRATOR:LEILANI ALEJANDROFACILITY TYPE:
735
ADDRESS:840 STATE COLLEGE BLVD., S.TELEPHONE:
(714) 563-2392
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 5DATE:
12/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Leilani Alejandro - AdministratorTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Lydia Martinez and Alvaro Ramirez, Jr. conducted an unannounced visit for the purpose of conducting a required annual visit. Two Clients were unsupervised waiting outside for approximately one hour due to no Staff present at the facility. At 3:01pm, Administrator (AD) Leilani Alejandro arrived to the facility. LPAs were granted entry into facility. LPAs explained the reason for the visit.

At 3:08 p.m., LPAs and AD Alejandro conducted a tour inside of the facility, common areas, Client rooms, and kitchen. Three Clients were present during today’s visit. Facility is a 4-bedroom, 2-bathroom, and 1 Staff bedroom and bathroom, single story home with an attached garage. LPAs observed a screening and sanitizing station at the entrance of the facility. Clients were observed watching television. All Client rooms had required elements, including bed, chair, nightstand, closet space, and ample lighting. Restrooms are stocked with soap and paper towels and have hand washing posting signs. Facility has required Department postings including Valid License, Complaint Poster (PUB 475), Emergency Disaster Plan, Infection Control Plan and Personal Rights. LPAs observed the facility to have approximately a two-day perishable and seven-day non-perishable supply of food for five Clients in care.

LPAs observed facility has 72-Hour emergency food and water supply. LPAs observed centrally stored medications are not kept locked. During tour in the sunroof room LPAs observed bottles of vitamins, bottles of over the counter medication such as pain relievers. LPAs toured the outside grounds and observed the shaded outside visitation area. Exit gates are unlocked and self-closing. All Staff and all Clients are vaccinated for COVID-19. LPAs observed a four-week supply of PPE.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with AD Alejandro, and a copy of this report, LIC 809-D, and Appeal Rights was provided at time of exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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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Document Has Been Signed on 12/08/2022 04:38 PM - It Cannot Be Edited


Created By: Alvaro Ramirez Jr. On 12/08/2022 at 03:58 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: STATE ROYALE GUEST HOME
FACILITY NUMBER: 306003567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80078
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.

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. LPA observed two unsupervised Clients waiting in the front of the facility due to no Staff being present which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 12/09/2022
Plan of Correction
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Licensee agrees to submit a written plan of action to ensure Staff coverage is available at all times. POC to be submitted by 12/09/2022.
Type A
Section Cited
CCR
80075(k)(1)
(k) The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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. LPA observed centrally stored cabinet to be unlocked and over the counter bottles of medication, bottles of vitamins and bottles of pain reliever were observed unlocked in the sunroof patio accessible to Clients which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 12/09/2022
Plan of Correction
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Staff locked away over the counter medication and medicine cabinet was locked. Licensee to conduct in-service Staff training on section cited and submit proof to LPA by 12/15/2022.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022


LIC809 (FAS) - (06/04)
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