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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006245
Report Date: 04/02/2024
Date Signed: 04/04/2024 02:42:47 PM


Document Has Been Signed on 04/04/2024 02:42 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:A CROWN ROYALE SENIOR HOMEFACILITY NUMBER:
306006245
ADMINISTRATOR:AVILA, MARIA JASMINFACILITY TYPE:
740
ADDRESS:24855 CROWN ROYALETELEPHONE:
(714) 609-2303
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 6DATE:
04/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Cristobal TongsonTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Cristobal Tongson. Cristobal Tongson's Administrator's Certificate expires on October 31, 2024. LPA observed the PUB 475 sign in the entry way of the facility. The facility is a single story home with 5 bedrooms, 2 bathrooms, living room with a fireplace, dining room, kitchen, laundry room and an attached 3 car garage. LPA and Administrator toured the facility. LPA observed the kitchen is clean and organized. LPA observed a 2-day perishable and a 7-day non-perishable food supply on hand in the kitchen. Cleaning supplies are kept secured under the kitchen sink. Knives and sharp objects are kept secured in a kitchen drawer. Medication is kept locked in a kitchen cabinet. LPA inspected the first aid kit which has all the required elements. The fireplace in the living is screened. LPA observed all 5 resident rooms had the required furnishings. All resident rooms were clean and organized. Both bathrooms are clean and operational. Hot water measured 111.7 degrees Fahrenheit in both bathrooms. LPA observed the laundry room is kept locked and inaccessible to residents. LPA and Administrator toured the garage and backyard. The garage is kept locked and used for storage. No bodies of water observed in the backyard. There is a covered patio with a table and chairs to sit outside. The single exit gate is latched and operational. No obstacles or hazards observed inside or outside of the facility. LPA observed all fire extinguishers are fully charged. The smoke detectors/carbon monoxide detectors tested operational. LPA reviewed 6 resident files, no discrepancies observed. LPA reviewed 4 staff files no discrepancies observed. LPA consulted with the Administrator concerning reporting requirements and continued training requirements for all staff. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
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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