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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003567
Report Date: 12/17/2024
Date Signed: 12/17/2024 05:21:01 PM

Document Has Been Signed on 12/17/2024 05:21 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:STATE ROYALE GUEST HOMEFACILITY NUMBER:
306003567
ADMINISTRATOR/
DIRECTOR:		LEILANI ALEJANDROFACILITY TYPE:
735
ADDRESS:840 STATE COLLEGE BLVD., S.TELEPHONE:
(714) 563-2392
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 4DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Leilani AlejandroTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility to conduct a Required - 1 year inspection. LPA met and was allowed entry into the home by Staff Elisa Roque. Licensee/Administrator (AD) Leilani Alejandro arrived shortly after. AD Alejandro has an Administrator Certificate expiring on 12/02/2025. There were two clients present and two at Program during today's visit. LPA, along with AD toured the physical plant. LPA observed the facility for the most part to be clean and in good repair. The home is maintained at a comfortable temperature. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked and toilets and water faucets worked properly. Toilets and bathtubs need deep cleaning. Hot water temperature was within regulatory requirements. Client bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Kitchen is clean and needs to be organized. Perishable and non-perishable food supply was checked and adequately stocked. Appliances are operational during today's visit. LPA observed two knives in the kitchen, razors in clients room and cleaning supplies were under unlocked kitchen cabinet. Smoke detectors and carbon monoxide detectors tested operational; Fire extinguisher was fully charged and mounted. No bodies of water were observed outside. Walkways around the home were clear of hazards. Exit gates are unlocked. LPA observed First Aid kit contained required items. Last Emergency/Fire Drill was conducted on 11/24/2024 and are conducted monthly. LPA observed emergency supplies including food and water in the sunroom. LPA reviewed four client files and one staff file. Client and staff files contained required documentation. Medication was observed to be in a centrally stored location and some medication was observed accessible to the clients and medication reviewed appeared to have been dispensed accurately. P & I money matched facility ledger. Liability and Surety Insurance certificates are current.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and Appeal Rights was discussed with AD and copies sent to email on file.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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 12/17/2024 05:21 PM - It Cannot Be Edited


Created By: Lydia Martinez On 12/17/2024 at 04:04 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: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087
Buildings and Grounds: (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger...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 facility failed to ensure disinfectants, cleaning solutions, sharps...that could pose a danger...were unlocked. LPA observed bottles of disinfectant sprays and bleach located in an unlocked kitchen cabinet under the sink and a knives in an unlocked kitchen drawer and on dishwasher dryer and razors in client's bathroom. Client bathrooms need a deep clean; kitchen needs to be organized. This poses an immediate health and safety risk to clients in care.
POC Due Date: 12/18/2024
Plan of Correction
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CORRECTED DURING VISIT as dangerous items were locked away. Licensee agrees to ensure that all disinfectants, cleaning solutions, poisons...and other items that could pose a danger are made inaccessible to clients in care; bathrooms will be clean and kitchen organized and will provide proof of understanding to Community Care Licensing on the regulation cited by 12/18/2024. Will also provide an in-service with staff by on or before 01/17/2025.
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/17/2024 05:21 PM - It Cannot Be Edited


Created By: Lydia Martinez On 12/17/2024 at 04:25 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: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075
Health Related Services: (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 and interviews, the facility failed to ensure that medications were 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. LPA observed several bottles medication belonging to staff in unlocked kitchen cabinet and two packs of medication belonging to client on table in the sunroom. This poses an immediate health and safety risk to clients in care.
POC Due Date: 12/18/2024
Plan of Correction
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CORRECTED DURING VISIT. Medication was locked away. Licensee agrees to ensure that all medications are made inaccessible to clients in care. Licensee will provide proof of understanding to Community Care Licensing on the regulation cited on or by 12/18/2024. Licensee to conduct in-serice training with staff and submit proof of training by 01/17/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
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