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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881033
Report Date: 11/27/2023
Date Signed: 11/27/2023 03:30:58 PM


Document Has Been Signed on 11/27/2023 03:30 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:ROYALTY SENIOR LIVINGFACILITY NUMBER:
331881033
ADMINISTRATOR:RILEY, TA'NEISHAFACILITY TYPE:
740
ADDRESS:10104 KINGS CTTELEPHONE:
(951) 416-1064
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
92509
CAPACITY:6CENSUS: 6DATE:
11/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Ta'Neisha Riley, AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a case management visit. LPA Prieto met with Administrator Riley. LPA Prieto toured facility and found that the facility is clean and free of odors. No obstructions outside, in hallways or bedroom entries. LPA Prieto observed recently fire cleared bedrooms. The facility appears to be in compliance relating to title 22 regulations. LPA also had administrator Riley sign amended complaint report 56-AS-20230501085745. This report (LIC 809) and amended complaint report (LIC 9099) were signed by LPA Prieto and administrator Riley and a copy was left at the home.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023
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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