306006245-4-3-2023-22-AS-CGUZ-CQJPFK-20230403111649

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006245
Report Date: 04/03/2023
Date Signed: 04/03/2023 11:17:04 AM

Document Has Been Signed on 04/03/2023 11:17 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	A CROWN ROYALE SENIOR HOME		FACILITY NUMBER:	306006245
ADMINISTRATOR:	AVILA, MARIA JASMIN		FACILITY TYPE:	740
ADDRESS:	24855 CROWN ROYALE		TELEPHONE:	(714) 609-2303
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY: 6		CENSUS: 6	DATE:	04/03/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Maria Avila		TIME COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility and was greeted and granted entry by designated Administrator (AD) Maria Avila. On-call Administrator Priscilla Celis, and Assistant Administrator Cristobal Tongson were also present.. An application to operate an Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden residents was received by CCL on 9/15/2022. Structure: The facility is a single-story house with five resident bedrooms, three bathrooms, living room, kitchen, laundry room, staff office, and an attached three car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entrance area. There is a back yard with one exit gate on one side of the house. There is a shaded seating area in the backyard. LPA did not observe any obstacles or hazards in the backyard. Resident Bedrooms All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. Signal system There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked in the laundry room.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023

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: A CROWN ROYALE SENIOR HOME	FACILITY NUMBER: 306006245
	VISIT DATE: 04/03/2023

NARRATIVE

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Medications, First-Aid Kit & Book:
Medication will be stored in a locked cabinet. First aid kit was observed to be kept in a hallway cabinet and a second first aid kit is mounted on the wall in the laundry room. The first aid kits had all the required elements.

Resident & Staff Files:
Records will be kept locked in storage cabinet located in the kitchen.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
Fire extinguisher is fully charged.

Reading Material, Games, Equipment & Materials:
The facility has board games and card games for resident use.

Fire clearance:
Was approved by a fire inspector of Orange County Fire Authority on 03/15/2023. Special conditions noted “Under current setup, no bedrooms can house bedridden clients. Bedroom doors to remain closed due to open hallway with common areas. (For exiting purposes). Exit pathways for bedrooms 4 & 5 need to be direct exit through sliding glass doors in rooms.”

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bedrooms Staff:

Staff will not be living on site. There is a staff office.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: A CROWN ROYALE SENIOR HOME	FACILITY NUMBER: 306006245
	VISIT DATE: 04/03/2023

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Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 114 degrees Fahrenheit.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was posted and visible.

Food Service:
There is a supply of 2-day perishable and 7-day of non-perishable food on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Electric four burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023

LIC809 (FAS) - (06/04)

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