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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003568
Report Date: 03/09/2023
Date Signed: 03/09/2023 04:41:13 PM

Document Has Been Signed on 03/09/2023 04:41 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ROYALE BEST CARE HOMEFACILITY NUMBER:
306003568
ADMINISTRATOR:LEILANI & NOLAN ALEJANDROFACILITY TYPE:
735
ADDRESS:12051 GILBERT STREETTELEPHONE:
(714) 530-8181
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: 3DATE:
03/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:16 PM
MET WITH:Leilani Alejandro, Licensee/Administrator, Nolan Alejandro, Administrator, May Dumlao, Assistant Administrator and Janette Baltazar, Caregiver and Jaqueline Puente, Regional Center of Orange County Quality Assurance CoordinatorTIME COMPLETED:
04:40 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 today’s date, Licensing Program Analyst (LPA) Rosie Quiroz conducted a Case Management- Deficiencies visit in conjunction with the ten-day complaint inspection visit for Complaint Control #22-AS-20230301135048.

During the course of the investigation of Complaint Complaint Control #22-AS-20230301135048, LPA Quiroz along with Licensee/Administrator (L/AD) Leilani Alejandro, Live in Caregiver (LCG) Janette Baltazar and Administrator (AD) Nolan Alejandro toured the interior and exterior of the facility. Between 12:21pm-1:01pm, LPA Quiroz toured the kitchen area along with (LCG) Baltazar and (L/AD) Leilani Alejandro. While inspecting the kitchen area, LPA Quiroz observed red liquid stored in gallon milk container dated February 18. At 12:25pm, LPA Quiroz observed one dozen container of eggs with one egg remaining in container dated March 30, 2021, one full dozen container of eggs in clear container dated July 18, 2021 and a third container of Kirkland eggs dated February 16, 2023. At 12:47pm, LPA Quiroz observed ice cream cake in baskin robins box stored in refrigerator. LPA Quiroz and (RCOCQAC) Puente inquired why ice cream was being stored in refrigerator and not in the freezer. (LCG) Baltazar indicated not knowing why. Upon opening box of ice cream cake, LPA Quiroz observed cake green in color in appearance appearing to be mold. Between 12:48pm-12:56pm, LPA Quiroz observed lettuce stored in the refrigerator to be brown in color, peanut butter with expiration date of 11/10/22 and ketchup with expiration date of 12/22/22. LPA Quiroz inquired what was stored in unlabeled containers, however (LCG) Baltazar was not able to identify the food in the containers being stored in the refrigerator. Upon (LCG) Baltazar opened container red in color dated 01/31 with what appeared to look like corn a strong foul odor was detected by LPA Quiroz. All the observations noted above were verified with (L/AD) Leilani Alejandro, (AD) Nolan Alejandro and (LCG) Baltazar with (RCOCQAC) Jaqueline Puente present. (SEE LIC 809-D)

CONTINUED...

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023
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 4
Document Has Been Signed on 03/09/2023 04:41 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 03/09/2023 at 03:16 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: ROYALE BEST CARE HOME
FACILITY NUMBER: 306003568

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/10/2023
Section Cited
CCR
85076(d)(1)

1
2
3
4
5
6
7
85076 Food Service(d)The licensee shall meet the following food supply and storage requirements:(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.This requirement was not met as evidenced by:CONT...
1
2
3
4
5
6
7
(L/AD) Alejandro will read and understand CCR85076(d)(1), provide training to staff empoloyed at facility and submit proof of perishable and non perishable items purchased by 3/10/2023 COB.
8
9
10
11
12
13
14
Between 12:21pm- 1:01pm, while LPA Quiroz toured the kitchen area LPA Quiroz observed red liquid stored in gallon milk container dated February 18. At 12:25pm, LPA Quiroz observed eggs stored in refrigerator dated March 30, 2021, July 18, 2021 and February 16, 2023. CONT...
8
9
10
11
12
13
14
LPA Quiroz observed lettuce brown in color, ice cream cake observed green in color appearing to be mold, expired peanut butter, expired ketchup and container red in color with what appeared to look like corn with strong foul odor detected by LPA Quiroz. This was verified with (L/AD) Alejandro. This poses an immediate risk to clients in care.
Type A
03/09/2023
Section Cited
CCR80019(k)(1)

1
2
3
4
5
6
7
Criminal Record Clearance(k)(1):The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of volunteers that require fingerprinting and non-client adults residing in the facility.(1) Documentation shall be available for inspection by the Department.
CONTINUE...
1
2
3
4
5
6
7
LPA Quiroz requested for (LCG)s grandson to leave premises immediately.
Immediate risks reduced.
Immediate civil penalty was assessed on today's date.
8
9
10
11
12
13
14
This requirement was not met as evidenced by: Based on file review, interviews conducted with interviewees and observations conducted by LPA Quiroz, the Facility did no secure criminal background clearance for (LCG) grandson who was allowed to reside in facility and have direct contact with clients in care CONT...
8
9
10
11
12
13
14
without criminal background clearance since 12/09/2022. This poses immediate risk to the clients in care.
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:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/09/2023 04:41 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 03/09/2023 at 03:54 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: ROYALE BEST CARE HOME
FACILITY NUMBER: 306003568

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2023
Section Cited
CCR
80087(g)

1
2
3
4
5
6
7
Buildings and Grounds: 80087(g)Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.This requirement was not met as evidenced by:
1
2
3
4
5
6
7
L/AD Alejandro will provide staff identified on LIC 500 (Personnel Report) training on CCR80087(g) and submit proof of training by 3/13/2023.
(AD) Nolan Alejandro purchased padlocks and installed during today's visit.
8
9
10
11
12
13
14
At 12:18pm, LPA Quiroz observed unlocked disinfectants consisting of ajax, detergent, bleach and other cleaning disinfectants stored in 2 closet near laundry area. This poses a potential risk to clients 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ROYALE BEST CARE HOME
FACILITY NUMBER: 306003568
VISIT DATE: 03/09/2023
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
26
27
28
29
30
31
32
 CONTINUED...

At 12:18pm, while inspecting laundry area, LPA Quiroz observed unlocked disinfectants consisting of ajax, detergent, bleach and other cleaning disinfectants stored in 2 closets near laundry area. This poses a potential risk to clients in care. During today's visit, (AD) Nolan Alejandro purchased and installed padlocks. (SEE LIC 809-D)



At 1:05pm, while conducting interviews with staff, LPA Quiroz observed individual in caregiver’s bedroom. The individual identified self as (LCG)’s grandson who indicated he has been living at the facility since December 9, 2022. A written statement was obtained from (LCG)’s grandson. Upon reviewing personnel list, (LCG)s grandson was not associated with the facility, and there is no personnel record available at the facility. This was verified with (L/AD) Leilani Alejandro who indicated (LCG)’s grandson is just visiting from time to time. This poses an immediate risk to clients in care. Civil penalty assessed during today’s visit.

Facility is being cited. The following California Code of Regulation (CCR) deficiencies were observed during today’s unannounced visit:

CCR-85076 Food Service(d)(1)


CCR -Criminal Record Clearance(k)(1)
CCR- Buildings and Grounds: 80087(g)

Today’s report was reviewed with (L/AD) Leilani Alejandro, (AD) Nolan Alejandro, (AAD) May Dumlao and (LCG) Janette Baltazar, and a copy of this report, LIC 809-D pages, Civil Penalty Assessment (LIC 421 IM) and Appeal Rights were provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4