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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005985
Report Date: 12/31/2024
Date Signed: 12/31/2024 04:46:43 PM

Document Has Been Signed on 12/31/2024 04:46 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:ROYAL CARE FAMILY HOMESFACILITY NUMBER:
306005985
ADMINISTRATOR/
DIRECTOR:		ASIS, EMELYNFACILITY TYPE:
740
ADDRESS:506 N. ROYAL ST.TELEPHONE:
(562) 461-9820
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 5DATE:
12/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Rose Ann Asis AngTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On December 31, 2024, at 8:00am, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley was greeted and granted entry by Caregiver (CG) Maria Lorna Flores who called Licensee/Administrator (AD) Emelyn Asis by phone. Licensee Asis informed me that she was out of town and would send Administrator (AD) Rose Asis Ang to facilitate the tour in her place. AD Asis Ang arrived at the facility around 8:45am. AD Asis Ang has a current administrator certificate with an expiration date of August 3, 2026.

The facility is licensed to operate for six (6) residents of which two (2) may be non-ambulatory, and a hospice waiver for four (4) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, (1) staff bedroom, two (2) bathrooms, living room area, dining area, kitchen, an outdoor covered seating area, and an attached two car garage. There are currently five (5) residents in care and all were present during today’s visit.

Around 9:00am, LPA Bentley toured inside and outside of the physical plant with AD Asis Ang. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for each resident’s personal belongings was observed. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, and Resident Room 4, and one Staff Bedroom. Bathrooms were found to be clean and operational. The water temperature measured between 111.4 degrees F to 119.1 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility.

LPA Bentley observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE: DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024
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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Document Has Been Signed on 12/31/2024 04:46 PM - It Cannot Be Edited


Created By: Eboni Bentley On 12/31/2024 at 02:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROYAL CARE FAMILY HOMES
FACILITY NUMBER: 306005985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(b)
Limitations -Capacity and Ambulatory Status
(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, record review and interview, licensee currently has a total of three non-ambulatory residents ocuppying three resident rooms. The licensee did not comply with the section cited above for resident (R3) according to physcian's report and fire clearance. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2025
Plan of Correction
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Administrator states that one resident is actually ambulatory and will meet with doctor to update physician's report. She also plans to have residents switch rooms and will send proof to CCLD via email to
eboni.bentley@dss.ca.gov by Jauary 9, 2025
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Eboni Bentley
LICENSING EVALUATOR SIGNATURE:
DATE: 12/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/31/2024 04:46 PM - It Cannot Be Edited


Created By: Eboni Bentley On 12/31/2024 at 02:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROYAL CARE FAMILY HOMES
FACILITY NUMBER: 306005985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in five out of five resident files (R1-R5), which posed a potential health, safety or personal rights risk to persons in care. LPA observed resident files missing pre-appraisals for all five residents.
POC Due Date: 01/09/2025
Plan of Correction
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Administrator states that she will complete pre-appraisals for all five residents (R1-R5) and will send proof to CCLD via email to eboni.bentley@dss.ca.gov by Jauary 9, 2025
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in five out of five resident files (R1-R5), which posed a potential health, safety or personal rights risk to persons in care. LPA observed resident files missing bedrail physician's orders for all five residents.
POC Due Date: 01/09/2025
Plan of Correction
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Administrator states that she will acquire bedrail orders from doctor for all five residents (R1-R5) and will send proof to CCLD via email to eboni.bentley@dss.ca.gov by Jauary 9, 2025
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Eboni Bentley
LICENSING EVALUATOR SIGNATURE:
DATE: 12/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2024


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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: ROYAL CARE FAMILY HOMES
FACILITY NUMBER: 306005985
VISIT DATE: 12/31/2024
NARRATIVE
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During the visit, LPA Bentley observed the facility's infection control practices, plan of operation, and fire and disaster plan. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-630-3212) remains available, and the facility has a device that can be used for video teleconference purposes. Emergency water, and additional supplies were stored in the garage.

The facility has one (1) fire extinguisher that was observed charged, mounted in the dining area, and serviced on July 22, 2024. Liability Insurance is effective August 11, 2024 and expires on August 11, 2025. First aid kit is properly maintained and contains all the necessary elements.

LPA Bentley conducted an audit of five (5) resident files (R1-R5), four (4) staff files (S1-S4), and medication administration review. LPA Bentley conducted two (2) staff interviews and five (5) resident interviews.


Based on observations made during today’s inspection, deficiencies were cited during the time of the visit per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Administrator Rose Asis Ang.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024
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