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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800347
Report Date: 03/24/2023
Date Signed: 03/24/2023 03:43:48 PM


Document Has Been Signed on 03/24/2023 03:43 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:ROYAL CARE HOMEFACILITY NUMBER:
425800347
ADMINISTRATOR:LEILANIE ACOSTA VEAFACILITY TYPE:
740
ADDRESS:338 EAST CRESTON DRIVETELEPHONE:
(805) 925-9441
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 5DATE:
03/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Leilanie Acosta Vea, Administrator/LiceneseeTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Jenny Olson conducted an unannounced Annual visit to the facility above. LPA met with Leilanie Acosta Vea at 10:05 AM, and explained the purpose of the visit. Administrator stated there are 5 residents currently living in the facility.

The facility has 5 bedroom's and 3 bathrooms. 2 resident bedrooms are occupied by single residents, one double room is occupied by a single resident and one double room is occupied by 2 residents. One room is being used as an office. LPA observed all necessary postings in the living room.

LPA toured the entire inside and outside of the facility with Administrator. There is ample room outside for residents to be outdoors with a table, chairs and awning for shade. LPA observed the refrigerator, cabinets, microwave, and oven to be clean with enough food for residents. Medications were observed locked and secured in a cabinet located in the office. Around 2:30 PM LPA tested the water temperature and observed it was at 105 degrees F. At 2:35 PM LPA tested the fire/carbon monoxide detector and observed them to be working and operational. LPA observed the facility to be clean and in good repair with all passageways and exits to be free and clear of debris and obstacles.

Around 10:15 AM LPA reviewed facility staff files for completeness. Around 10:45 AM LPA reviewed facility resident records for completeness. Around 11:30 AM LPA and Administrator conducted a full CARE Tool Facility Inspection. Around 12:40 PM LPA observed a fire extinguisher charged and last inspected on 2/13/23. Around 12:45 PM LPA Interviewed 2 staff and 2 residents who were present. Around 2:00 PM LPA conducted a cursory medication audit and reviewed CSMDR and medications paperwork and discussed with administrator the importance of keeping it up to date. .

Exit Interview conducted, a copy for the report was issued to facility.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
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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