306003568-12-9-2024-22-AS-MTEA-DBSRF2-20241209115824

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003568
Report Date: 12/09/2024
Date Signed: 12/09/2024 11:58:36 AM

Document Has Been Signed on 12/09/2024 11:58 AM - 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:	ROYALE BEST CARE HOME		FACILITY NUMBER:	306003568
ADMINISTRATOR/ DIRECTOR:	LEILANI & NOLAN ALEJANDRO		FACILITY TYPE:	735
ADDRESS:	12051 GILBERT STREET		TELEPHONE:	(714) 530-8181
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY: 6		CENSUS:	DATE:	12/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Leilani Alejandro		TIME VISIT/ INSPECTION COMPLETED:	12:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by Direct Support Professional (DSP) Donabel Esguerra. Administrator (AD) Leilani Alejandro arrived shortly to assist with the visit. Facility is licensed for six clients and two may be non-ambulatory. Currently there are four clients residing.

Around 8:15 AM, LPA Tea reviewed three client files and two staff files. Client and staff files had most of the required documentation. There were a few discrepancies upon reviewing client and staff records. Client records had only Orange County Regional Center admission agreements. LPA advised to include a separate admission agreement for licensing that meets Title 22 standards. Looking at the staff records there were no, health screenings. AD Alejandro’s administrator certificate has an expiration date of March 1, 2026. She has not received a physical copy yet due to backlog.

LPA Tea along with AD Alejandro and DSP Esguerra toured the facility at 9:17 AM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a single-story home that consists of 3 client bedrooms, 3 staff rooms, 3 bathrooms, living room, dining room, and kitchen. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured very high at 141.8 F degrees. LPA explained to AD and staff that water temperature needs to be between 105 F degrees to 120 F degrees, anything higher needs warning signs posted around the bathroom faucets. Staff adjusted the water temperature and posted warning signs. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors.

Annual continuation on LIC809-C

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

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 12/09/2024 11:58 AM - It Cannot Be Edited

Created By: Michael Tea On 12/09/2024 at 10:38 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: ROYALE BEST CARE HOME	FACILITY NUMBER: 306003568
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(10)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation of facility records, there are no health screenings in staff records. This could pose as a potential health and safety risk to clients in care.
	POC Due Date: 12/23/2024
	Plan of Correction
1 2 3 4	Licensee will provide proof of health screening for staff by POC due date to LPA

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:

Alisa Ortiz

LICENSING EVALUATOR NAME:

Michael Tea

LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

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: ROYALE BEST CARE HOME	FACILITY NUMBER: 306003568
	VISIT DATE: 12/09/2024

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Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps and toxins locked in cabinets by the kitchen in the laundry area. The fire extinguisher by the front entry way is fully charged and last serviced on February 22, 2024. Kitchen appliances are operational during today's visit with the exception of one of the stove burners not in use not lighting up properly. It needed to be cleaned. LPA toured the outside grounds and there is ample seating with shade in the backyard and front porch area. LPA observed emergency supplies, food and water supply in the storage closet in the hallway. Facility provides activities based on client interests. The clients dance and exercise. They also go for walks around the neighborhood and go shopping and outside on the weekends to eat. At the time of annual visit, most of the clients were attending day programs.

LPA reviewed medication storage and administration. Medications are stored in a locked cabinet in the living room. Medications are being administered per physician. LPA checked P&I Funds and discovered no discrepancies. LPA spoke to staff present regarding care provided.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator Leilani Alejandro and a copy of these reports were given to the facility along with a copy of the LIC858; 859;809-D, 9102 and Appeal Rights

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC809 (FAS) - (06/04)

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