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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006089
Report Date: 12/17/2024
Date Signed: 12/17/2024 05:01:38 PM

Document Has Been Signed on 12/17/2024 05:01 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 SENIOR LIVINGFACILITY NUMBER:
306006089
ADMINISTRATOR/
DIRECTOR:		BASTANI, ASHKANFACILITY TYPE:
740
ADDRESS:31742 ISLE ROYAL DR.TELEPHONE:
(949) 302-3696
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 6DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Ashkan BastaniTIME VISIT/
INSPECTION COMPLETED:
05:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Administrator Ashkan Bastani and explained the reason for the visit. The Administrator's certificate expires on October 22, 2025. Facility is licensed for a capacity of 6 non-ambulatory residents of which one can be bedridden and hospice waiver for 4. Facility is a singe story home with 5 bedrooms (1 is for staff), 2 bathrooms, kitchen, living room, dining room and a two car garage. The garage is kept locked and used for storage. Facility is operating within it's license. LPA observed the fireplace in the living room is screened. LPA observed the See Something Say Something Poster posted in the hallway next to the front door. LPA observed the kitchen is clean and organized. The 5 burner gas stove lights unassisted. LPA observed the cleaning supplies are kept locked under the kitchen sink and knives are kept locked in a kitchen drawer. The fire extinguisher in the kitchen is fully charged. Medication is kept locked in a cabinet in the hallway. LPA observed a clean linen supply in the hall closet. LPA observed all resident rooms had the required furnishings. LPA observed both bathrooms are clean and operational. Hot water measured 120.0 degrees Fahrenheit in both bathrooms. LPA observed Resident 1 (R1) had a bed rail on their bed but did not have a doctor's order for a bed rail. LPA observed the backyard had a table with chairs and an umbrella to sit outside. No bodies of water observed in the backyard. Both exit gates are operational. No obstacles or hazards observed in the backyard. LPA reviewed resident files and medications. LPA observed 5 out of the 6 resident files had no discrepancies. Resident 1 had a bed rail but no doctor's order for a bed rail. Smoke detectors/carbon monoxide detectors were tested. There is a smoke detector in each hallway on both sides of the house, both smoke detectors (2) in the hallways were not operational. All smoke detectors in the living room and in each bedroom are operational. During the visit the batteries were changed in the 2 smoke detectors in the hallways and both hallway smoke detectors are now operational. LPA reviewed 2 staff files, there was no documentation for any current training for both staff members. LPA observed Staff 1 had current CPR/First aid training. The last fire drill was conducted on November 10, 2024. The first aid kit has ll the required elements.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 12/17/2024 05:01 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 12/17/2024 at 03:17 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 SENIOR LIVING
FACILITY NUMBER: 306006089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
FIRE SAFETY: All facilities smoke detectors shall be maintained in conformity with the regs adopted by the State Fire Marshal for the protection of life and property against fire and panic.

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, LPA observed the smoke detector in each hallway (2) are not operational which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Licensee agrees to replace both smoke detectors in each hallway (2) and to submit proof to LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/17/2024 05:01 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 12/17/2024 at 03:40 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 SENIOR LIVING
FACILITY NUMBER: 306006089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.


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 1 out of 1 residents, LPA observed R1 has a bed rail but does not have a docto's order for a bed rail, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Licensee agrees to remove the bed rail and to only mount bed rails for any resident after receiving a doctor's order for a bed rail.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


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Document Has Been Signed on 12/17/2024 05:01 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 12/17/2024 at 04:45 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 SENIOR LIVING
FACILITY NUMBER: 306006089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 2 out of 2 staff members, LPA observed Staff 1 and Staff 2 did not have any current training documented, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Licensee agrees to have both Staff 1 and Staff 2 trained as required by the regulation above and to submit proof of training to LPA>
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


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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 SENIOR LIVING
FACILITY NUMBER: 306006089
VISIT DATE: 12/17/2024
NARRATIVE
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Facility has a dedicated internet device for resident use. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. A civil penalty was issued on this date. An exit interview was conducted with the Administrator and a copy of the report along with appeal rights and LIC 421IM (civil penalty) was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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