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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202520
Report Date: 12/10/2021
Date Signed: 12/10/2021 02:15:32 PM

Document Has Been Signed on 12/10/2021 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:ROYAL GARDENS IVFACILITY NUMBER:
107202520
ADMINISTRATOR:GURMIT K AULAKHFACILITY TYPE:
740
ADDRESS:1125 SUNNYSIDE AVE.TELEPHONE:
(559) 765-4905
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 6DATE:
12/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Gurmit Aulakh, AdministratorTIME COMPLETED:
01:45 PM
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On 12/10/2021, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Donnaly (Donna) Tanaka, caregiver. LPA toured facility with caregiver. Gurmit Aulakh, Administrator was called and arrived shortly during tour. All six residents were present during the inspection.

Upon entry facility staff was observed facial mask on. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing postings in facility. LPA observed fire extinguisher served date: 02/09/21. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked under kitchen sink. LPA checked residents’ locked medications and observed a small amount of 30-day PPE supplies.

All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. LPA observed hand washing posting by all sinks. All resident’s room toured and observed to be adequately furnished and lit. LPA observed 2 bedrooms that are single occupant and 2 shared resident’s bedrooms to be at least 6 feet apart.

The exterior tour was conducted. Side gate was self-closing and self-latching. Staff records were reviewed for good health and infection control training. A sample of resident’s records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 12/16/21. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610E, Lic 9020, control of property, current liability insurance. LPA received Administrator Certificate and health screening during facility inspection.

Administrator was informed that as COVID-19 precautionary measure, this report will be provided via email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2021
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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