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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005936
Report Date: 05/27/2022
Date Signed: 05/27/2022 02:06:57 PM


Document Has Been Signed on 05/27/2022 02:06 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:
05/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Administrator, Yaninee AsawadilokchaiTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit for the purpose of conducting a case management follow up to excepting new residents into facility. LPA Tirre met with Administrator Yaninee Asawadilokchai and did a walk through of facility. Facility rooms have required furniture, Facility has secured location for medications, files, sharps and toxins. Smoke detectors and alarms at entrances/exits are operational.

Administrator was advised to obtain department requirements for food and was informed to have 2 days perishable foods and 7 days non perishables. Facility has food however LPA advised Administrator that food needed more nutritional value. Administrator is looking to have new resident move in by next week and acknowledged understanding of food requirements.

LPA receive LIC 500 from Administrator and Administrator will send updated copy of Administrators certificate. LPA observed Administrators certificate expiring 10/23/2023. Facility sketch and Emergency Disaster plan posted on wall.

An exit interview was conducted with Administrator and copy of report left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
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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