306005188-5-13-2026-22-AS-WVAS-DU2VAT-20260513161627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005188
Report Date: 05/13/2026
Date Signed: 05/13/2026 04:17:20 PM

Document Has Been Signed on 05/13/2026 04:17 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:	ROYAL PALMS CARE HOME		FACILITY NUMBER:	306005188
ADMINISTRATOR/ DIRECTOR:	FREDRIC ROBART		FACILITY TYPE:	740
ADDRESS:	5929 LOS RAMOS CIRCLE		TELEPHONE:	(714) 625-9425
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 6		CENSUS: 6	DATE:	05/13/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Fredric Robart (Administrator)		TIME VISIT/ INSPECTION COMPLETED:	04:30 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 today's date Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes of completing an annual inspection. Upon arrival LPA was greeted and granted entry to the facility by care giving staff. Administrator (AD) Fredric Robart was notified via telephone and arrived shortly after in order to assist with the annual inspection. LPA conducted a tour of the facility and observed the following. AD does not have a valid Administrator certificate a deficiency was issued on today's date. The facility is a one storied home with six bedrooms two of which are utilized for two and four are utilized for residents in care. The facility is equipped with a detached two car garage. LPA observed the kitchen area to be clean and free of any mildew and debris. LPA observed the kitchen area to be equipped with a refrigerator, microwave, and gas stove. All appeared to be in good repair and tested operational. LPA observed the facility to have a two day supply of perishable food and a seven day supply of non-perishable food along with a sufficient amount of emergency water on hand. LPA observed all resident rooms to be clean and free of any debris and hazards. LPA observed the resident bedrooms to be large enough to walk about freely. LPA observed all bedrooms to have all required furnishings including a chair, a lamp, a bed, clean linens in good repair; meaning no strains or tears, a chest of drawers, and enough storage space to store personal belongings. LPA observed all facility restrooms to be clean and free of any mildew and debris. LPA observed all restrooms to have all required furnishings such as grab bars, slip resistant floor matts, and a shower chair. LPA observed all water faucets and toilets to be in good repair and tested operational. Hot water temperature tested between 111.3 and 114.4 degrees Fahrenheit. CONTINUED ON LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: ROYAL PALMS CARE HOME	FACILITY NUMBER: 306005188
	VISIT DATE: 05/13/2026

NARRATIVE

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LPA observed all smoke detectors and carbon monoxide detectors to be in good repair, and tested operational. LPA observed all fire extinguishers to be fully charged and had an updated service tag on them. LPA observed first aid kit to have all required items including scissors, tweezers, adhesive tape, bandages, a thermometer, and a first aid manual.

LPA conducted a tour of the outside of the facility and observed the following. The backyard of the facility is large enough to participate in outdoor activities upon resident request. LPA observed the backyard to be free of any debris or large objects. LPA observed side exits to be free of any hazards or debris blocking the side exits. LPA observed the side doors to be unlocked and self latching.

LPA reviewed six resident files and three staff files. All files (staff and resident) were complete and had all required items. Annual staff training was updated and documented correctly. LPA reviewed P&I with AD all balances were documented correctly and cash on hand matched P&I ledger. LPA Reviewed medications and medication administration record. Per LPA review all medications are being documented correctly and are being administered per physicians orders. Based on today's observations a deficiency will be issued per title 22 chapter 6 division 8 of the California Code of Regulations, an exit interview was conducted and a copy of this report was provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/13/2026 04:17 PM - It Cannot Be Edited

Created By: William Vanegas On 05/13/2026 at 04:03 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: ROYAL PALMS CARE HOME	FACILITY NUMBER: 306005188
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87406(a)

Administrator Certification Requirements

(a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the Administrator certificate observed to be hung up on the wall was expired, and the CDSS website did not have any pedning applications for a renewed Administrator certificate which poses a potential saftey risk to persons in care.
	POC Due Date: 06/03/2026
	Plan of Correction
1 2 3 4	Administrator agrees to complete his required trianing and contact Centralized Application Bureau to start the process of renewing their Administrator certificate.

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.

	Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:

	William Vanegas
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

LIC809 (FAS) - (06/04)

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