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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006089
Report Date: 10/14/2022
Date Signed: 10/14/2022 01:13:12 PM


Document Has Been Signed on 10/14/2022 01:13 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:ROYAL SENIOR LIVINGFACILITY NUMBER:
306006089
ADMINISTRATOR:BASTANI, ASHKANFACILITY TYPE:
740
ADDRESS:31742 ISLE ROYAL DR.TELEPHONE:
(949) 302-3696
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 5DATE:
10/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Rey Reyno, Ashkan BastaniTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by staff. LPA explained the reason for the visit. Facility is a single story home with 5 bedrooms and 2 bathrooms, kitchen, living room, dining room and a 2 car attached garage. Administrator Askan Bastani's Administrator's certificate expires on 10/22/2023. LPA and staff toured the facility. LPA observed all resident bedrooms were clean and organized and had the required furnishings. LPA inspected both bathrooms. Both bathrooms were clean and operational. Hot water measured 110.6 degrees Fahrenheit in both bathrooms. LPA observed the fireplace in the living room was screened. LPA toured the kitchen. LPA observed a two day perishable and a seven day non-perishable food supply on hand. LPA observed the stove top lights unassisted. Knives and sharp objects are kept locked in a kitchen cabinet. LPA observed medication is kept locked in a kitchen cabinet. The kitchen is clean and organized. LPA observed linens are kept in a cabinet in the hallway. The linens were clean and in good condition. No obstacles or hazards were observed inside the facility. LPA and staff toured the backyard. LPA observed a table with an umbrella and three chairs on the patio. Both exit gates on each side of the house are operational. No bodies of water observed. No obstacles or hazards observed in the backyard. Administrator Ashkan Bastani arrived at 12:25 pm. Smoke detectors and the carbon monoxide detector tested operational. LPA inspected the first aid kit. The first aid kit had all the required elements. LPA consulted with Administrator concerning continued Covid-19 mitigation procedures. No deficiencies observed during today's visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted with the Administrator and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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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