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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005936
Report Date: 04/28/2022
Date Signed: 04/28/2022 04:39:40 PM


Document Has Been Signed on 04/28/2022 04:39 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: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:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator, Yaninee AsawadilokchaiTIME COMPLETED:
04:50 PM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit for the purpose of conducting required annual inspection.

LPA arrived at facility was greeted at the door by administrator and granted entry. During today’s visit, LPA met with Administrator Yaninee Asawadilokchai and explained the reason for visit. LPA toured the facility and inspected the physical plant of the facility, no residents were observed at facility. LPA was informed there are no residents currently residing at facility and only occupant is administrator. LPA was informed that facility has no residents and the last resident that resided at facility was December of 2021. Licensee will contact Community Care Licensing (CCL) to inform of when they are ready to accept new residents or if there are any changes with the license. LPA was informed Administrator just paid the annual fee for license. Facility has operating smoke detectors and carbon monoxide detectors. Facility also has emergency food and water.

At this time there were no deficiencies to report in the facility. As noted above, Licensee will contact CCLD once residents are being admitted. In an effort to update the facility file, the Administrator is required to submit to the licensing agency a copy of the following:

- An updated Personnel Report (LIC 500).

- Copy of Administrator Certificate.

This report was reviewed with administrator and a copy of this LIC809 report was provided

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
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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