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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006605
Report Date: 10/24/2024
Date Signed: 10/24/2024 10:51:12 AM

Document Has Been Signed on 10/24/2024 10:51 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 CARE FAMILY HOMES 2FACILITY NUMBER:
306006605
ADMINISTRATOR/
DIRECTOR:		ASIS, EMELYNFACILITY TYPE:
740
ADDRESS:824 S CHANTILLY STTELEPHONE:
(562) 275-2670
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 0DATE:
10/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Emelyn AsisTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Lydia Martinez made an announced visit to conduct a Pre-Licensing inspection. LPA identified herself and was granted entry into the home. An initial application to operate an Residential Care Facility for the Elderly (RCFE) was submitted to Community Care Licensing on 07/01/2024 for a capacity of six (6) Residents. Applicant Emelyn Asis has an Administrator certificate valid until 03/12/2025. Upon entry, facility appears clean, safe and sanitary.

LPA along with Applicant toured the facility and observed the following:
Structure: Facility is a one story, 5 bedroom, 3 bathroom house with an attached garage. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Resident: Two rooms will be single occupancy and other two will be double occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: Resident bathrooms have a working toilet/wash basin. Facility has sanitizer/soap in the bathrooms. Linens & Hygiene Supplies: Facility has adequate bedding, towels and hygiene supplies for Resident in care. Emergency Phone Numbers and Exit Plan: Emergency plan/phone numbers will be located in facility entrance. Food Service: Applicant understands to have a 2 day supply of perishables and a 7 day of non-perishables at all times when Residents are present. There are no Residents present during this inspection. LPA observed ample emergency food and water as well as a facility menu. Smoke Detectors: Smoke detectors/carbon monoxide detectors are hard wired and were tested operational. Fire extinguishers is mounted and charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/Sharps: Facility has secured area for toxins/sharps under kitchen sink. Water Temperature: Tested and hot water temperature was within regulatory requirements.

(cont...LIC809C)
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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 CARE FAMILY HOMES 2
FACILITY NUMBER: 306006605
VISIT DATE: 10/24/2024
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Medications, First-Aid Kit & Book: First aid kit observed contained all required items, including First Aid Manual. Facility to be stored in Medication cabinet located in living room and will use a Medication Administration record.

Resident & Staff File: Records to be stored in a locked medication cabinet. Reading Material, Games, and Equipment: Facility has a variety of board games, music, books, and magazines.

Backyard: LPA observed a clean backyard with umbrellas over seating for Residents and visitors. Exit gates observed unlocked.

Fire Clearance: Approved on 08/02/2024. Rooms 1, 2, 3 non-Ambulatory, Room 4 Ambulatory and Room 5 for Caregiver.

The Applicant is an existing Licensee and has completed the Component III in the past. Component III will be waived during today’s visit. Applicant demonstrates and exhibits a clear concise comprehensive knowledge of medication protocols, documentation, and wound preventative care.

The Pre-Licensing evaluation has been completed. It appears this facility meets the requirements for licensure. The license will be granted upon completion of a final review and approval from the Application Specialist.

An exit interview was conducted with Applicant. This report will be sent to email on file.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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