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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603741
Report Date: 05/05/2023
Date Signed: 05/05/2023 03:10:42 PM

Document Has Been Signed on 05/05/2023 03:10 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ROYER ARFFACILITY NUMBER:
374603741
ADMINISTRATOR:ROYER, TAMARAFACILITY TYPE:
735
ADDRESS:2598 STARKEY WAYTELEPHONE:
(619) 445-0035
CITY:ALPINESTATE: CAZIP CODE:
91901
CAPACITY: 4CENSUS: 1DATE:
05/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee Tamara "Tammy" RoyerTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Licensee Tamara "Tammy" Royer.

Today's visit was in response to licensee's self-reported death of Client #1 (C1), received at the CCLD San Diego Regional Office on 05/03/2023. [See LIC 811 Confidential Names List for a description of C1]. Per the report, C1 passed away on 05/01/2023.

LPA performed a facility tour / welfare check on the remaining client in care, collected pertinent records, and interviewed relevant staff. No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Royer, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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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