331881033-1-20-2021-18-AS-JGEE-BXG2K6-20210120162724

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881033
Report Date: 01/20/2021
Date Signed: 01/20/2021 04:27:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ROYALTY SENIOR LIVING		FACILITY NUMBER:	331881033
ADMINISTRATOR:	RILEY, TA'NEISHA		FACILITY TYPE:	740
ADDRESS:	10104 KINGS CT.		TELEPHONE:	(562) 335-0636
CITY:	JURUPA VALLEY	STATE: CA	ZIP CODE:	92509
CAPACITY:	6	CENSUS: 0	DATE:	01/20/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	03:01 PM
MET WITH:	Ta'neisha Riley Licensee		TIME COMPLETED:	04:30 PM

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	On 1/20/21 Licensing Program Analyst (LPA) Javina George conducted an announced visit for the purpose of conducting a pre-licensing inspection. Upon arrival LPA met with Licensee/Administrator Ta'neisha and Lance Riley as well as Director Linda Kimbrough whom assisted with the inspection. The facility is a single story house with (5) resident bedrooms (4 private and 1 shared), and 3 bathrooms, a living room that staff can use to complete assessments, family room, kitchen with a dining area, laundry room, activity room, and a 2 car garage. There is a marble pool, and fire pit located in the backyard. The backyard also has a shed that will be used for storage. On 11/25/2020, the Riverside County Fire Department approved the facility for 6 ambulatory residents. During today's inspection, LPA toured the interior and exterior of the facility. The medications will be centrally stored and locked in a closet located in the hallway opposite of the Master bedroom. The smoke and carbon monoxide detectors are operable. There were 4 fully charged fire extinguishers observed. All cleaning supplies are locked in a cabinet located in the laundry room and underneath the kitchen sink. The sharp objects will be stored in a lock box, inside of the panty located inside of the kitchen. All doors, and passageways are clear from obstruction and were equipped with night lights. There is a fire place located in the family room that is screened and covered with glass. All beds have the required linen and supplies. There was a sufficient amount of clean linen and hygiene items stored in two cabinets located in both hallways. There was appropriate lighting in each room. There are no fire arms or ammunition stored at the facility.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ROYALTY SENIOR LIVING	FACILITY NUMBER: 331881033
	VISIT DATE: 01/20/2021

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
26
27
28
29
30
31
32

The hot water was tested and ranged from 106.6-108.1 degrees F. All kitchen appliances operate properly. The bathrooms are equipped with grab bars and non-skid floor mats and/or surfaces.

All garbage cans have tight fitting lids. The facility is stocked with a 2 day supply of perishables and a 7 day supply of non-perishable food items. The facility was stocked with dishes, tableware, and utensils in good repair and enough for the capacity. The resident and staff files will be locked in a cabinet located inside of the garage. LPA observed the emergency disaster plan, facility sketch, personal rights, and theft and loss policy, PUB 475 complaint poster hung on the wall in the entryway.

There was adequate seating in the common areas. There is 1 stocked first aid kit with 1 manual. The facility is stocked with activities; such as books, magazines, puzzles and board games to provide entertainment and encourage socialization for the residents and are located in the activity room.

An exit interview was conducted and a copy was at the facility with Licensee/Administrator's Ta'neisha and Lance Riley as well as the Director Linda Kimbrough.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2