<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003567
Report Date: 03/07/2023
Date Signed: 03/07/2023 03:18:23 PM

Document Has Been Signed on 03/07/2023 03:18 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:
03/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Leilani Alejandro, AdministratorTIME COMPLETED:
01:30 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 this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting a case management visit regarding deficiencies observed during the investigation of complaint #22-AS-20230301140104. LPA was greeted and granted entry by caregiving staff. Administrator Leilani Alejandro arrived later to assist with the visit.

LPA accompanied by caregiver conducted a tour of the physical plant and observed the following: Upon arriving at the facility, LPA attempted to use the doorbell, which was found to not be functional. LPA resorted to knock, which facility staff did not immediately hear either. An Technical Assistance Advisory Note to that extent is being issued.

The mounted fire extinguisher observed on the kitchen wall shows a maintenance tag for a revision conducted in July 2021, which means the maintenance update need to be done by the end of the month of July 2022. Due to a misunderstanding, the vendor contracted by the licensee changed the extinguishers at one location operated by the licensee but not at State Royale Guest Home.

A type B deficiency is being cited per Title 22 of the California Code of Regulations.

An exit interview was conducted and a copy of this report along with appeal rights was provided and left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2023
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 2
Document Has Been Signed on 03/07/2023 03:18 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 03/07/2023 at 02:31 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: 03/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2023
Section Cited
CCR
80087(a)

1
2
3
4
5
6
7
The California Code of Regulations Section 80087(a) on Buildings and Grounds states that: "The facility shall be (...) safe (...) and in good repair at all times for the safety and well-being of clients, employees and visitors." This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee reached out to their contracted vendor during the visit to conduct the annual maintenance on the fire extinguisher. The deficiency was cited and cleared during the visit.
8
9
10
11
12
13
14
Based on observation conducted during a tour of the physical plant, the maintenance for the mounted fire extinguisher has been expired since July 2022. This poses a potential risk to the health, safety and personal rights of the individuals in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2