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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000688
Report Date: 11/03/2021
Date Signed: 11/03/2021 03:00:02 PM

Document Has Been Signed on 11/03/2021 03:00 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ROYAL INN, THEFACILITY NUMBER:
306000688
ADMINISTRATOR:ALAN L. SHELLEYFACILITY TYPE:
740
ADDRESS:23272 DOWNLANDTELEPHONE:
(949) 472-9001
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 5DATE:
11/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Hannah Shelley and Rubio "Jona" CayetanoTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Staff Jona Cayetano and Hannah Shelley. Administrator Alan Shelley was out of town and could not come to the visit. The focus of the visit was Infection Control. LPA toured the facility with Rubio Cayetano and the following was observed:

Covid signs were posted at the front entrance of facility with a sanitization station. LPA's temperature was taken upon arrival and a sign in sheet was available. Facility has required Department postings. Administrator Certificate for Alan Shelley expires on 3/24/23. Restrooms observed contained soap, paper towels and toilet paper. Hand sanitizer, soap, wipes and gloves were present and in sufficient supply. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. Residents were napping and in their rooms watching tv. Social distancing and masks for staff were observed. Licensee has required Mitigation plan and Emergency Disaster Plan. Facility has emergency food and water supply. Facility has a secured storage for medication and files. All residents have at least a 30 day supply of medications.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of mask wearing and handwashing for staff. Administrator is reminded to review PIN 20-17.2-ASC in regards to Visitation, Dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment. As well as PIN 21-32.1- ASC Updated Facility Staff Testing and Masking Guidelines. No deficiencies noted during visit. An exit interview was conducted and a copy of this report was provided to Hannah Shelley.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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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