306004632-8-22-2022-22-AS-KSGH-CHJU9C-20220822152256

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004632
Report Date: 08/22/2022
Date Signed: 08/22/2022 03:23:10 PM

Document Has Been Signed on 08/22/2022 03:23 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:	ROYAL RCFE		FACILITY NUMBER:	306004632
ADMINISTRATOR:	CRISTIANA STAN		FACILITY TYPE:	740
ADDRESS:	2547 E. NORM PLACE		TELEPHONE:	(714) 758-2804
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92806
CAPACITY:	6	CENSUS: 5	DATE:	08/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Crispin Lalu, caregiver Renee Fuehrer, Administrator		TIME COMPLETED:	03:45 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 08/22/2022 at 1:30pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection focusing on Infection Control procedures. LPA was greeted and granted entry by caregiver Crispin Lalu. Administrator Renee Fuehrer was notified by telephone and arrived shortly afterwards to assist with the visit. At approximately 2:15pm, LPA accompanied by administrator toured the physical plant of the facility. There are currently four (4) residents in care and an additional resident currently hospitalized for surgery. The residents are observed relaxing in the common area or in their bedroom and appear clean and well taken care of. The six (6) bedrooms include all necessary components. An ample supply of linen is observed. The three (3) bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected. Sharp instruments are stored in a kitchen drawer secured by a key lock. The centrally stored medication and resident files are located in a locked closet near the office. Cleaning supplies are also located in the locked attached garage and in a cabinet under the sink. The magnetic lock for the cabinet are observed to not be fully functional. LPA observed a sufficient supply of food and water present. LPA observed the facility has COVID-19 Precautions posters and all required department postings. A Technical Advisory is issued in regards to both the reporting of COVID-19 positive cases and monitoring of temperatures for incoming visitors. Staff present is adequately cleared in Guardian, however current staff is found to not be associated to the facility in Guardian following a change of staff in January 2022. A Technical Advisory regarding the need to perform and maintain the association in question is issued to the facility's representative. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

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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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: ROYAL RCFE	FACILITY NUMBER: 306004632
	VISIT DATE: 08/22/2022

NARRATIVE

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CONTINUED FROM FORM LIC809

LPA and administrator toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture and a shaded area is present for the enjoyment of residents and visitors. The perimeter gate is self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Based on the observations made during today’s visit, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. Two (2) Technical Advisory notices are issued regarding staff association and COVID-19 reporting requirements. This report was reviewed with facility representative and a copy of this report along with appeal rights was provided and left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/22/2022 03:23 PM - It Cannot Be Edited

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: ROYAL RCFE	FACILITY NUMBER: 306004632
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(f)

The California Code of Regulations Section 87705(f) indicates that "The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants." This requirement is not met as evidenced by the presence of a non-functioning magnetic lock on the left door of the cabinet under the kitchen sink.
	Deficient Practice Statement
1 2 3 4	Based on observation conducted during today's visit, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/02/2022
	Plan of Correction
1 2 3 4	Licensee will ensure the repair or the replacement of the left side kitchen sink cabinet magnetic lock, so that cleaning supplies stored there are fully secured.

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	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

LIC809 (FAS) - (06/04)

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