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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200872
Report Date: 11/12/2021
Date Signed: 11/12/2021 04:23:09 PM

Document Has Been Signed on 11/12/2021 04:23 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,
, CA
FACILITY NAME:ROYAL PALM RESIDENTIAL HOMEFACILITY NUMBER:
019200872
ADMINISTRATOR:MENDIOLA, MARIA CORAZONFACILITY TYPE:
740
ADDRESS:39606 ROYAL PALM DRIVETELEPHONE:
(510) 661-0239
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 6DATE:
11/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Maria Corazon Mendiola TIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Administrator Maria Corazon Mendiola. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. LPA was greeted by live-in staff and Administrator who arrived later. All staff wore masks during the visit.
LPA conducted a walk-through of the facility with live-in staff Conrado Francisco and observed COVID-19 precaution postings. A screening station was observed at front entrance of facility for visitors and staff. LPA's temperature was taken by staff. Staff follow indoor visitation requirement of verifying COVID-19 vaccination or a negative COVID test within 72 hours for visitors. The facility has designated visitation areas, provides virtual visits and phone calls for family to stay in contact with clients. Staff and client's temperatures are taken once a day and LPA observed documentation. Staff clean and disinfect the facility twice daily. Staff stated high touched surface areas are disinfected after each use. Staff have documented completion on the following training: infection prevention, symptoms, transmission and PPE use; LPA observed documentation. The facility has a supply of PPE including gloves, face shields/goggles, N-95 respirators, surgical masks and disposable gowns. N-95 respirator Fit testing (Cal/OSHA requirement) has been completed; LPA observed proof of N-95 respirator fit testing - cards in file. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services (CDSS), Community Care Licensing (CCL). LPA discussed with Administrator screening visitors for COVID-19 symptoms and screening questions to be documented. LPA discussed implementing a sign-in/out log for client (C1). LPA verified C1 can leave the facility unassisted (per LIC 602)
LPA requested the following updated documents to be submitted to CCLD Oakland Regional Office by 11/29/2021:
· LIC500 – Personnel Report
· LIC 9020 – Register of Facility Residents
· LIC308 – Designation of Administrative Responsibility (one staff name per form)
· LIC610E – Emergency Disaster Plan
· Administrator Certificate
· Proof of Liability Insurance
· Proof Surety Bond
Facility to notify the CCLD Oakland Regional Office if more time is needed to submit the forms.
Exit interview conducted with Administrator whose signature on this document confirms receipt.
No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
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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