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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000689
Report Date: 12/24/2024
Date Signed: 12/24/2024 01:19:35 PM

Document Has Been Signed on 12/24/2024 01:19 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ROYAL INN II, THEFACILITY NUMBER:
306000689
ADMINISTRATOR/
DIRECTOR:		ALAN L. SHELLEYFACILITY TYPE:
740
ADDRESS:22841 RIDGE ROUTE DRIVETELEPHONE:
(949) 581-8220
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 6DATE:
12/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:House Manager - Madison ShelleyTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Brandon Lopez and Licensing Program Manager (LPM) Sheila Santos made an unnannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by caregivers staff after explaining the purpose for the visit. House Manager (HM) Madison Shelley was notified via telephone and later arrived to assist with the inspection. LPA observed that Administrator Alan Shelley has a valid Administrator certificate which expires on March 24, 2025.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents with a hospice waiver for four. The facility is a single-story home with six private resident bedrooms, one staff room, two shared bathrooms, a living room, a dining room, a kitchen, and an unattached two car garage. LPA accompanied by the HM conducted a tour of the physical plant. On today's visit, LPA observed six residents in care and two caregiver staff present. LPA observed residents eating their breakfast in the dining room as well as eating in their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall by the kitchen. LPA inspected the six resident bedrooms and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed that four residents had full bed rails. LPA observed additional linens are stored in a hallway closet. LPA inspected the two shared bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non skid floor mats. Hot water temperature measured between 114.2 and 114.8 degrees Fahrenheit. LPA inspected the staff bedroom and observed it to be unlocked and accessible to residents. LPA observed three chemical products that were observed to be stored in the staff bedroom. HM immediately removed the chemicals and locked it.

LPA observed the kitchen has a two day perishable and seven day non perishable food supply on hand. LPA observed kitchen knives are stored in a locked kitchen cabinet. LPA observed cleaning supplies are stored in a locked kitchen cabinet under the sink. A fire extinguisher is located in a hallway by the kitchen and it was observed the be charged and serviced up to date 2/18/24. CONTINUED ON LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/24/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II, THE
FACILITY NUMBER: 306000689
VISIT DATE: 12/24/2024
NARRATIVE
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LPA tested the wired smoke detector/carbon monoxide detector which tested operational. LPA observed the facility conducted their last emergency disaster drill on October 1, 2024.The centrally stored medication is kept in a locked cabinet by the kitchen. LPA observed the First Aid kit has all the required components. The unattached garage is kept locked and inaccessible to resident. The garage is used for storage. LPA observed the facility has an emergency food and water supply stored in the garage.

LPA and HM conducted a tour of the exterior portion of the facility. LPA observed the laundry room was unlocked and accessible to residents. LPA observed toxins stored in the laundry room. HM immediately removed chemicals and locked them. LPA observed a chemical was left unattended on the southside of the property. HM immediately removed the chemical and locked it. LPA observed two ladders were left unattended. HM immediately removed them and locked them in the garage. LPA observed a shaded seating area with furniture for resident use. Their are no bodies of water on the premises.

LPA reviewed the six resident files. LPA observed that one of six resident's did not have a physician's report on file. LPA observed that two of four resident's did not have physician orders for full bed rails. HM immediately removed the bed rails. LPA reviewed six residents medication and medication records. LPA reviewed six staff files. LPA observed that Staff #2 (S2) was not associated to the facility. Civil penalties assessed.

Based on today's observations, the facility is being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with House Manager Madison Shelley. A copy of the report was explained and Appeal Rights were provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/24/2024 01:19 PM - It Cannot Be Edited


Created By: Brandon Lopez On 12/24/2024 at 12:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROYAL INN II, THE
FACILITY NUMBER: 306000689

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed cleaning chemicals and toxins in an unlocked staff room, an unlocked laundry room, and on the southside exterior of the facility.
POC Due Date: 01/01/2025
Plan of Correction
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HM immediately removed the cleaning supplies and toxins and now inaccessible to the residents. Citation was cleared at time of visit and HM will review the regulation with all the staff. Proof of training will be provided to LPA via email or fax by the due date.
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. Upon staff file review, LPA observed Staff #2 has been working for the facility since 03/19/2021 and observed to be not associated to the facility since 2022 to current per Department mailed facility roster infromation dated 8/31/22 and 8/31/23. Facility failed to follow up to ensure association is in place for Staff #2.
POC Due Date: 01/01/2025
Plan of Correction
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HM completed the LIC9182 to request association for Staff #2 and provided it to LPA during time of visit. Defieciency cleared during visit and a civil penalty was issued.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Brandon Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/24/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/24/2024 01:19 PM - It Cannot Be Edited


Created By: Brandon Lopez On 12/24/2024 at 12:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROYAL INN II, THE
FACILITY NUMBER: 306000689

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. During file review, LPA observed that Resident #1 does not a physician's report on file.
POC Due Date: 01/08/2025
Plan of Correction
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House Manager agreed to get a Medical Assessment for Resident #1 and submit to LPA via email or fax by the due date.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During tour of the physical plant, LPA observed Resident #4 and Resident #6 have full bed rails. Upon file review, Resident #4 and Resident #6 did not have a physician's order for full bed rails.
POC Due Date: 01/01/2025
Plan of Correction
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HM immediately removed the full bed rails in Resident #4 since resident is no longer under hospice care and Resident #6 bedrail physician's order was missing during file review.
HM will provide the physicians order for resident #6 via email or fax to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Brandon Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/24/2024


LIC809 (FAS) - (06/04)
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