306005936-4-9-2021-22-AS-JTIE-BZWMXJ-20210409100002

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005936
Report Date: 04/09/2021
Date Signed: 04/09/2021 10:00:07 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 CARE		FACILITY NUMBER:	306005936
ADMINISTRATOR:	ASAWADILOKCHAI, YANINEE		FACILITY TYPE:	740
ADDRESS:	6001 ROYALIST DRIVE		TELEPHONE:	(714) 655-6454
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92647
CAPACITY:	6	CENSUS: 0	DATE:	04/09/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Administrator, Yaninee Asawadilokchai		TIME COMPLETED:	09:53 AM

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Licensing Program Analyst (LPA) Jenifer Tirre contacted the facility via telephone to conduct a subsequent 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 and Administrator toured the facility via Face Time and observed the following:

Licensee had required postings posted near the entry of facility
Licensee has emergency food and water supply
Licensee has first aid kit with first aid manual
Licensee has sharps secured in a locked storage
Licensee has thermometer to check water temperature. Water temperature was tested and recorded at 113.5 degrees to 114.0 degrees Fahrenheit
Licensee has shaded outdoor seating for residents
Licensee has placed Non-skid mats inside showers/tubs
Licensee has grab bars in every restroom
Licensee has dresser and chairs for each resident in resident rooms
Licensee repaired gate latch for fence to properly close/open

CONTINUED ON 809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021

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: 04/09/2021

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CONTINUED FROM 809

Licensee has working telephone for residents to use

Licensee/Administrator has completed the noted corrections and is ready to be licensed.

An exit interview was conducted with Administrator Asawadilokchai 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 Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021

LIC809 (FAS) - (06/04)

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