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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600602
Report Date: 01/30/2025
Date Signed: 01/30/2025 06:56:12 PM

Document Has Been Signed on 01/30/2025 06:56 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ROYAL ILIMAFACILITY NUMBER:
415600602
ADMINISTRATOR/
DIRECTOR:		GANIO, PUREZA A.FACILITY TYPE:
740
ADDRESS:1565 ROYAL AVE.TELEPHONE:
(650) 348-3895
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
01/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Pureza Gano, Carmelita Cumlat, Betty GanoTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
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LPA Audrey Jeung toured facility and grounds of this facility that serves elderly developmentally disabled persons. There are 3 shared client bedrooms, activity room, 2 full bathrooms, kitchen and living/dining room on ground floor. There is a bathroom and 2 staff rooms on 2nd floor; one room has 5 beds and the other has 2 beds. The washer and dryer are located in attached 1-car garage and extra supplies are stored in storage shed in backyard. There are no accessible bodies of water or fire safety hazards observed. Toxins, medications and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. First-aid kit is complete. Some client files are reviewed, and medications are recorded on Centrally Stored Medications Records. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff training records. Pureza Ganio (x 8/25) and Antolin Ucol (x 11/25) are certified RCFE administrators that oversee facility operations. Night staff is awake.

As per legislation, effective 1/1/2015, the following information is posted: 1) PUB474, pertaining to resident councils, per AB1572; 2) text of Health and Safety Code 1569.269 AND CCR Title 22 Section 87468 (Personal Rights form LIC613C), per AB2171; 3) CCLD Hotline information, per SB895.

Proof of control of property (current signed lease) is requested to be submitted to CCLD BY 2/13/25.

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on a following page. Also, see Advisory Notes issued--2 pages.
April CowanTELEPHONE: (650) 266-8889
Audrey JeungTELEPHONE: (650) 266-8891
DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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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Document Has Been Signed on 01/30/2025 06:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: ROYAL ILIMA
FACILITY NUMBER: 415600602

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of staff records, the licensee did not comply with the section cited above in 3 out of 4 staff records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- There is no evidence that staff #1, #2, #4 have received training on postural supports.
POC Due Date: 02/13/2025
Plan of Correction
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Documentation that staff #1, #2, #4 received required training on postural supports will be sent to CCLD BY DUE DATE.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of disaster drill documentation, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
- Emergency disaster drills are not conducted and documented quarterly. Disaster drills were conducted April 2024, January 2024 and November 2023.
POC Due Date: 02/13/2025
Plan of Correction
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Emergency disaster drills will be conducted and documented at least quarterly. Proof/plan of correction to be sent to CCLD BY DUE DATE.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April CowanTELEPHONE: (650) 266-8889
Audrey JeungTELEPHONE: (650) 266-8891

DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025

LIC809 (FAS) - (06/04)
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