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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000688
Report Date: 12/31/2024
Date Signed: 01/03/2025 08:43:29 AM

Document Has Been Signed on 01/03/2025 08:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ROYAL INN, THEFACILITY NUMBER:
306000688
ADMINISTRATOR/
DIRECTOR:		ALAN L. SHELLEYFACILITY TYPE:
740
ADDRESS:23272 DOWNLANDTELEPHONE:
(949) 472-9001
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 4DATE:
12/31/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Alan Shelley, Samantha Dimichina,Madison ShelleyTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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 Licensing Program Analysts (LPAs) Hanna Gough, Nancy Guillen and Licensing Program Manager Sheila Santos were notified of a death that occurred while conducting the annual visit today.

Per staff Samantha, R1 passed away today and was under hospice care. Mortuary arrived to pick up R1.
Facility provided a death report LIC624A at the time of our visit. Per death report, death was caused by natural causes, cardiac arrest.

An exit interview was conducted and a copy of this report was explained and provided via email due to printer error.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Nancy Guillen
LICENSING EVALUATOR SIGNATURE: DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024
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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