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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005188
Report Date: 05/06/2025
Date Signed: 05/06/2025 10:37:02 AM

Document Has Been Signed on 05/06/2025 10:37 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 PALMS CARE HOMEFACILITY NUMBER:
306005188
ADMINISTRATOR/
DIRECTOR:
FREDRIC ROBARTFACILITY TYPE:
740
ADDRESS:5929 LOS RAMOS CIRCLETELEPHONE:
(714) 625-9425
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 6DATE:
05/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:35 AM
MET WITH:Frederic RobartTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of completing the required one-year annual inspection. LPA Haley was greeted and granted entry by staff and explained the reason for the visit. Administrator (AD) Fredric Robart has a current Administrators certificate that expires May 10, 2026.

Royal Palms Care Home is a one-story community with six bedrooms and two bathrooms. Four bedrooms are for residents and two bedrooms are for staff. The facility capacity is 6 and the census was 6 during the annual visit. All residents were observed in the living room watching television waiting on rides to take them to their day programs.

During the inspection, all bedrooms and bathrooms were observed. Resident bedrooms had all the requirements and were in compliance with regulation guidelines. Resident bathrooms were in compliance as well. No hazardous cleaning items were observed. Grab bars were tightly secured to the wall. Hot water temperatures were measured in both bathrooms. In bathroom #1 hot water measured at 106.5 degrees Fahrenheit, and in bathroom #2 hot water measured at 107.2 degrees Fahrenheit.

Carbon monoxide detectors were observed in both hallways near resident rooms and both tested operational. All smoke detectors observed in resident bedrooms, and the common areas tested operational.

In the kitchen knives and sharp objects are locked in a drawer near the stove. Resident medications are locked in the cabinet along with a first aid kit that had all the required items including a first aid manual. The stove was clean, and all four burners were operational on the gas stove. A fully charged fire extinguisher was observed behind the refrigerator.

Continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 PALMS CARE HOME
FACILITY NUMBER: 306005188
VISIT DATE: 05/06/2025
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The backyard was clean, organized and walkways were free of obstruction. A patio area with a table and chairs was observed. There were two storage sheds in the backyard. Both sheds were used to store personal items that belong to staff. One shed contained boxes of clothing, and the other shed contained miscellaneous items that belong to staff.

The garage is used to store various items. There were two locked cabinets used to store hazardous cleaning solutions, detergents, and hygiene supplies. An additional refrigerator and freezer with an additional perishable food supply, and an additional nonperishable food supply was observed. An emergency supply of water and several containers of emergency food was observed on the shelves with the supply of nonperishable items. A laundry area was also observed in the garage with a washer and dryer.

There’s an office area in between the backyard and kitchen. There’s a computer, a couple desk, posting boards, and a copy machine in the office area. There’s two locked cabinet areas in the office area. One of the locked areas is for resident and staff files and the other locked area is for resident P&I funds.

An emergency evacuation drill was conducted April 12, 2025, and are conducted quarterly.

During the inspection four resident files were reviewed, four resident medications were reviewed, four resident P&I funds were reviewed, 3 staff files were reviewed, and two staff and one resident were interviewed.

No deficiencies are being cited as a result of today’s visit.

An exit interview was conducted, and a copy of this report was provided to Administrator Fredric Robart.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jerome Haley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC809 (FAS) - (06/04)
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