306006337-9-11-2023-22-AS-DLMN-CVKPGS-20230911111849

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006337
Report Date: 09/11/2023
Date Signed: 09/11/2023 11:20:13 AM

Document Has Been Signed on 09/11/2023 11:20 AM - 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ROYAL SWEET HOME CARE		FACILITY NUMBER:	306006337
ADMINISTRATOR:	ARMIN DARBANDI		FACILITY TYPE:	740
ADDRESS:	22305 SAVONA		TELEPHONE:	(949) 502-1364
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	6	CENSUS:	DATE:	09/11/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Armin Darbandi - Administrator		TIME COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility at 8:30am and was greeted and granted entry by designated Administrator (AD) Armin Darbandi. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (4) ambulatory, (1) non-ambulatory, and (1) bedridden clients was received by Community Care Licensing (CCL) on 4/4/2023. Structure: The facility is a one-story home with six resident bedrooms, three resident bathrooms, two half bathrooms, one staff office, living room, kitchen, dining room, an attached two car garage and backyard. All doors leading to the backyard are equipped with alarms to notify staff when they are opened. LPA observed PUB 475 See Something Say Something poster posted in entryway. There is a back yard with two exit gates. The facility has two shaded sitting areas. LPA observed a basketball hoop, table, chair and doors on the side of the house. LPA confirmed with AD that objects on side of the house are scheduled to be moved. Client Bedrooms: All resident bedrooms had the necessary furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked in the garage. Medications, First-Aid Kit & Book: Medication will be stored in a locked cabinet in the staff office. The First Aid Kit will be stored on a table in the hallway. LPA confirmed with the AD that a more extensive First Aid Manual will be purchased and kept with the first aid kit. Resident & Staff Files: Records will be kept in a locked cabinet in the staff office.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROYAL SWEET HOME CARE	FACILITY NUMBER: 306006337
	VISIT DATE: 09/11/2023

NARRATIVE

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Fire Extinguisher: LPA observed two fire extinguishers to be fully charged as indicated by the arrow pointing in the green zone. LPA observed the proof of purchase for the fire extinguisher which indicates it was purchased on 9/11/23

Reading Material, Games, Equipment & Materials: The facility has board games, art supplies, puzzles and books on a shelf in the hallway.

Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 04/12/2023.

Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bathrooms: The bathrooms have working plumbing. Hot water measured at 111.3 degrees Fahrenheit in the BR 6 Bathroom, 111.5 degrees Fahrenheit in the Bathroom across from the office and entryway, 113 degrees Fahrenheit in the Bathroom shared by BR 5 and BR 4, 112. 4 degrees Fahrenheit in the BR 1 Bathroom and 113.3 degrees Fahrenheit in the Bathroom shared by BR 3 and BR 2.

Linens & Hygiene Supplies: LPA confirmed with AD that a supply of extra linen will be purchased and stored in the garage. Extra hygiene supplies are stored in the garage.

Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review

Food Service: There is a 7-day supply of non-perishable food on hand.

Smoke Detectors: Detectors were observed to be dual smoke and carbon monoxide detectors that are wired through the home. Detectors were tested and operational.

Appliances: Gas stove, oven, refrigerators, dishwasher, microwave, washer and dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC809 (FAS) - (06/04)

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