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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005936
Report Date: 03/30/2021
Date Signed: 03/30/2021 11:38:18 AM

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:ROYALIST HOME CAREFACILITY NUMBER:
306005936
ADMINISTRATOR:ASAWADILOKCHAI, YANINEEFACILITY TYPE:
740
ADDRESS:6001 ROYALIST DRIVETELEPHONE:
(714) 655-6454
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 0DATE:
03/30/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Administrator, Yaninee AsawadilokchaiTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Jenifer Tirre contacted the facility via telephone to conduct a pre-licensing visit via Face Time due to COVID-19 and pre-cautionary measures. LPA identified themselves and discussed the purpose of the call with Administrator Yaninee Asawadilokchai. An initial application to operate a Residential Facility for the Elderly was received by CCL on 12/08/2020 for a capacity of 6 non-ambulatory residents. Pre-licensing is for initial licensure. There are 0 residents in care during today's visit.

LPA Tirre along with Administrator Asawadilokchai toured the facility via Face Time at 9:02 AM and observed the following:
Structure: Facility is a one story, 4 bedroom, 2 bathroom house with a separate garage and a gray exterior. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: Rooms are equipped with beds, lighting, and night stand. All rooms are missing a chair for each resident. One out of three rooms is missing accommodation of a dresser, Exit doors in facility are equipped with auditory exit alarms. Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower. One out of two restrooms is missing grab bar and both are missing Non-skid surface in the shower. Linens & Hygiene Supplies: Linen supply is ample supply for residents in care. Emergency Phone Numbers and Exit Plan: Facility does not have any items posted at the facility. Food Service: Facility has 2 day non-perishables. Facility is missing 7 day non-perishables in the pantry/ refrigerator, prior to admitting residents. Facility does not have an emergency food and water supply present at the facility. Smoke Detectors: Smoke detectors/ carbon monoxide detector are centrally wired and were tested operational. Fire extinguisher is mounted and charged. Appliances: Stove and refrigerator are operational. Facility microwave and washer/ dryer present at the facility. Toxins: LPA observed toxins locked and secured in laundry cabinet. Water Temperature: Was not tested due to facility missing thermometer. Running water does work in all sinks. Reading Material Games, and Equipment: Facility does not have any activity supplies present at the facility. CONTINUED ON LIC 809C DATED 3/30/2021
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021
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: ROYALIST HOME CARE
FACILITY NUMBER: 306005936
VISIT DATE: 03/30/2021
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Medications, First-Aid Kit & Book: Facility does not have a first aid kit or manual present at the facility. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility has fence with self latched gate. Latch on gate needs repair does not open/close properly. LPA did not observe any shaded, outdoor seating for residents. Fire Clearance: Approved for 6 non-ambulatory residents on 03/08/2021

The facility is NOT ready to be licensed. Component III was conducted. Licensee to correct the following items in order to be licensed:
  • All Community Care Licensing required postings to be posted in the entry of the facility including COVID-19 postings and visitors policy.
  • Facility to maintain an emergency food and water supply in the facility.
  • Facility to maintain a first aid kit including a first aid manual present at the facility.
  • Facility to obtain a secured area for sharps
  • Facility to obtain thermometer to test water temperature
  • Facility to obtain shaded, outdoor seating for residents
  • Facility to obtain non-skid mats for tubs/showers
  • Facility to obtain grab bar in restroom
  • Facility to obtain dresser in bedroom
  • Facility to obtain a chair in every room for each resident
  • Facility needs to fix gate latch for fence to close/open properly
  • Facility to obtain working telephone for residents use


Licensee to notify LPA upon completion of noted items. LPA will complete a visit to verify completion.

An exit interview was conducted with Licensee Vass via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021
LIC809 (FAS) - (06/04)
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