<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206335
Report Date: 08/30/2021
Date Signed: 08/30/2021 03:04:51 PM

Document Has Been Signed on 08/30/2021 03:04 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 BOARD AND CARE FOR ELDERLYFACILITY NUMBER:
107206335
ADMINISTRATOR:RIGON, RUDYFACILITY TYPE:
740
ADDRESS:3407 N. FRESNOTELEPHONE:
(559) 903-6846
CITY:FRESNOSTATE: CAZIP CODE:
93726
CAPACITY: 6CENSUS: 4DATE:
08/30/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Adminstrator, Rudy RigonTIME COMPLETED:
03:02 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Darius Williams conducted an unannounced Case Management visit in response to a report of Resident 1's (R1) AWOL. LPA Williams met with Administrator Rudy and Aurora Rigon.

R1 no longer resides at the facility.

LPA Williams interviewed Administrator Rudy and Aurora.

Administrator agreed to send the following documents for R1 to the Department by 4:00 PM on 9/6/2021; Emergency Contact Information (LIC 601), Admission Agreement, and Physicians Report (LIC 602).

Due to limited information available at this time, further investigation is required.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1