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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005188
Report Date: 05/06/2022
Date Signed: 05/06/2022 04:09:08 PM

Document Has Been Signed on 05/06/2022 04:09 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 PALMS CARE HOMEFACILITY NUMBER:
306005188
ADMINISTRATOR:FREDRIC ROBARTFACILITY TYPE:
740
ADDRESS:5929 LOS RAMOS CIRCLETELEPHONE:
(714) 625-9425
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 6DATE:
05/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Gladis Pachuca, Efrain Perez, Fredric RobartTIME COMPLETED:
04:15 PM
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Licensing Program Analysts (LPAs) Edward Tapia and MIchelle Reed made an unannounced required annual inspection in this facility. LPAs met with staff Gladis Pachuca and Efrain Perez and stated the purpose of this visit. Administrator Fredric Robart arrived during the visit at 2:00pm and provided assistance.

The facility is a single level structure and licensed for six ambulatory. This facility offers a Level IV- F service.

About 1:40 PM, LPAs Tapia, Reed were granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPAs observed six clients in care and two staff members on duty. LPAs toured the interior and exterior portions of the facility. There were three private client rooms, one shared room and two private staff rooms. Residents rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide, and auditory exit alarms were tested to be operational. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 107.9 degrees Fahrenheit. Bathroom( 2) was observed to be in good repair and provided with grab bars and hot water was measured at 105.8 degrees Fahrenheit. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to clients in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguishers were on observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. Facility had a two car garage with washer and dryer in good repair. Garage also stored emergency food. Kitchen was in good repair with sharps kept locked. LPAs Tapia and Reed reviewed the COVID 19 mitigation plan of the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ROYAL PALMS CARE HOME
FACILITY NUMBER: 306005188
VISIT DATE: 05/06/2022
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 LPAs discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No citation was issued. Two advisory notes were issued.

LPAs Tapia and Reed conducted an exit interview with Administrator Fredric Robart and copy of this report was left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC809 (FAS) - (06/04)
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