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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200872
Report Date: 10/07/2022
Date Signed: 10/07/2022 02:15:25 PM

Document Has Been Signed on 10/07/2022 02:15 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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: 5DATE:
10/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Fidela Balajadia, administrator assistant TIME COMPLETED:
02:20 PM
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On today’s date, 10/7/2022, at 1:10 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct Infection Control Inspection. LPA met with Fidela Balajadia, administrative assistant and explained the purpose of the visit. Maria Mendiola, Administrator shortly arrived at 1:46 PM and greeted LPA.

During the inspection, LPA toured facility including but not limited to common areas, hand washing stations, bedrooms, bathrooms, kitchen and backyard. LPA observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA observed PPE's are plentiful. Food and paper supplies are sufficient. Hand sanitizer is provided at facility entrance. Water temperature is measured at 109.6 degrees F in common residents bathroom. Fire extinguisher was last serviced on 9/26/2022. LPA observed facility passages inside and out are free of obstruction. First aid kit was observed to be complete. Smoke and carbon monoxide detectors were observed and maintained. Common areas are disinfected 3 to 4 times a day.

During record review, LPA observed facility has a copy of Infection Control Plan and emergency disaster plan on file.

No deficiencies cited during visit.

Exit interview conducted with Administrator and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2022
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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