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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005936
Report Date: 08/22/2024
Date Signed: 08/22/2024 01:35:52 PM


Document Has Been Signed on 08/22/2024 01:35 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: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: 5DATE:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Yaninee AsawadilokchaiTIME COMPLETED:
01:50 PM
NARRATIVE
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On 8/22/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with Administrator, Yaninee Asawadilokchai who was informed of the purpose of the visit.

LPA toured the facility with the administrator and observed the facility is made up of a one-story home with four (4) resident bedrooms, two (2) bathrooms, one (1) staff room, a kitchen, dining room, living room, and attached garage. During the tour, the administrator tested one (1) of the smoke alarms and carbon monoxide detectors and LPA observed it to be operational. LPA also observed a charged fire extinguisher mounted near the medication cabinet. Indoor and outdoor passageways were free of obstruction. The facility has outdoor shaded seating for the residents in care. There were no bodies of water observed on the premises. Medications are secured in a locked hallway cabinet. LPA toured the kitchen and observed the facility had a 2-day supply of perishable foods and 7-day supply of non-perishable food items. Staff present have a criminal record clearance and valid first aid/CPR certification.

During tour of the kitchen, LPA observed a mortar and pestle with white residue inside the mortar. Administrator reported the facility uses the mortar and pestle to crush Resident 1's (R1's) medications and camouflages them in their apple sauce at the request of R1's family. LPA requested to review R1's records and observed R1's file was incomplete and did not have a physician's report, pre-admission appraisal, functional capabilities assessment or appraisal/needs and services plan. The administrator reported the facility does not have a physician's order to crush/camouflage R1's medication and R1 is not cognizant to provide consent. Administrator also reported R1 is bed bound, unable to reposition themselves or independently transfer to and from bed, and requires to be repositioned by staff every two (2) to three (3) hours.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ROYALIST HOME CARE
FACILITY NUMBER: 306005936
VISIT DATE: 08/22/2024
NARRATIVE
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LPA interviewed R1's responsible person who corroborated the information reported by the administrator. Administrator and R1's responsible person reported R1 is not on hospice and is only receiving home health services at the facility twice per week. The facility did not have a copy of R1's home health care plan either. Per a Fire Safety Inspection Request (STD. 850) dated 2/22/2024, the facility has a fire clearance for six (6) non-ambulatory elderly residents.

During tour of the facility, LPA reviewed the Facility Sketch (LIC 999) and observed the "office" is being used as Resident 2's (R2's) bedroom and "Bedroom 4" is being used as a staff room. Administrator also reported a toilet was installed in R2's room (the "office") after the facility's fire inspection on 2/22/2024.

Based on the aforementioned the facility will be cited and assessed a civil penalty. An exit interview was conducted where this report was reviewed and provided to Administrator Asawadilokchai along with a Confidential Names List (LIC 811), LIC809-D and LIC421M.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/22/2024 01:35 PM - It Cannot Be Edited

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: ROYALIST HOME CARE
FACILITY NUMBER: 306005936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on an interview with Administrator Asawadilokchai and review of the Facility Sketch (LIC 999), the "office" is being used as Resident 2's (R2's) bedroom and resident "Bedroom 4" is being used as a staff room. Administrator reported they also installed a toilet in R2's room ("office") after the facility's fire inspection on 2/22/2024.which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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Licensee reported they will submit an LIC200 with a revised LIC999 reflecting the changes and request an appropriate fire clearance. Proof of correction to be emailed to LPA by close of business on 8/29/2024.
Type B
Section Cited
CCR
87465(a)(5)(D)
Incidental Medical and Dental Care Services
(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (D) Assistance with self-administration does not include forcing a resident to take medications, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Administrator reported the facility a mortar and pestle to crush R1's medication and camouflages it in their apple sauce at the request of R1's family. The administrator reported the facility does not have a physician's order to crush/camouflage R1's medication and R1 is not cognizant to provide consent, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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Licensee reported they will conduct a staff training regarding regulation 87465, Incidental Medical and Dental Care. Proof of correction to be emailed to LPA by close of business on 8/29/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 08/22/2024 01:35 PM - It Cannot Be Edited

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: ROYALIST HOME CARE
FACILITY NUMBER: 306005936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on an interview and record review, R1's resident file only contained a signed admission agreement, emergency ID contact information and did not have information commonly found on a physician's report, needs and services plan, functional capabilities assessment, and preappraisal which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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Licensee reported they will conduct a staff training regarding the Department's required resident records/information. Proof of correction to be emailed to LPA by close of business on 8/29/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 08/22/2024 01:35 PM - It Cannot Be Edited

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: ROYALIST HOME CARE
FACILITY NUMBER: 306005936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal...
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews conducted, R1 is unable to reposition themselves or independently transfer themselves to and from bed, requires cosistent repositioning by staff every two (2) to three (3) hours and is bedbound. Per a STD. 850 dated 2/22/2024, the facility has a fire clearance for six (6) non-ambulatory elderly residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee reported they will contact their local fire department and report the facility has a bedridden resident. Licensee added R1 will be relocated to a facility with an appropriate fire clearance. Licensee stated POC to be submitted to LPA via email by close of business on 8/23/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5