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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006658
Report Date: 04/02/2025
Date Signed: 04/02/2025 10:14:06 AM

Document Has Been Signed on 04/02/2025 10:14 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 MANOR CARE HOMEFACILITY NUMBER:
306006658
ADMINISTRATOR/
DIRECTOR:		BAYLON, RHADZIVILFACILITY TYPE:
740
ADDRESS:2547 E NORM PLACETELEPHONE:
(714) 930-5163
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 6CENSUS: 4DATE:
04/02/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:00 AM
MET WITH:William Manalo- Operator/CEO
Jarren Manalo- Administrator
Rhadzivil Baylon- Administrator		TIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Jessica Cho arrived announced for the purpose of conducting the Pre-Licensing visit for a Change of Ownership (CHOW). LPA conducted the visit with Applicant/Chief Executive Officer (CEO) William Manalo and Administrators (Admins) Jarren Manalo, BSN, RN and Rhadzivil Baylon. The initial application to operate a Residential Care Facility for the Elderly (RCFE) was received by the Department of Social Services on November 20, 2024 for age range 60 and over.

LPA toured the facility interior and exterior with Applicant William and Administrators Jarren and Radzivil. The following was observed:

Structure:


The facility is a single story property in a residential neighborhood comprised of six resident bedrooms with three resident full bathrooms and one staff bedroom. LPAs observed all common areas which includes the living room, dining area, kitchen, and an attached two car garage which doubles as a laundry area. There is a secured shed in the patio to store supplies. The backyard has sufficient shaded seating area and one exit gate.

Telephone Number:
Facility land line number (714) 844-2282 was tested and remains available.

Signal System:
No signal system, however residents utilize call buttons to alert the staff.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2025
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 MANOR CARE HOME
FACILITY NUMBER: 306006658
VISIT DATE: 04/02/2025
NARRATIVE
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Bedrooms:
The resident bedrooms had all required components, are spacious, and easily accommodates the residents’ furnishings.

Bathrooms:
Bathrooms were clean and operational. Grab bars were secure and bath slip mats were in place.

Linens and Hygiene Supplies:
Clean linens and hygiene supplies were observed to be fully stocked in the walk-in linen closet.

Appliances:
Stove burners, microwaves, refrigerator, freezer, and washer/dryer were inspected and operating.

Resident and Staff Files:
Resident and staff records will be maintained on site per administrators.

Reading Material, Games, Equipment, & Materials:
The facility maintains games and activities in the living room area.

Emergency Phone Numbers/Exit Plan:
Posted on the bulletin boards.

Postings:
The See Something, Say Something (PUB475) and the Ombudsman Posters were posted in the entry way in the correct size as well as the Rights of the Resident Councils, Resident's Rights, Theft & Loss Policy, Activity Schedule, and the Food Menu. A copy of the Admission Agreement is available upon request.

Food Service and Menu:
Supply of seven day non-perishable and two day perishables were observed in the kitchen and garage cabinet. The sample menu was posted on the bulletin board. The emergency food/water supply were also available in the garage.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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 MANOR CARE HOME
FACILITY NUMBER: 306006658
VISIT DATE: 04/02/2025
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Smoke and Carbon Monoxide Detectors:
The smoke detectors and carbon monoxide alert systems and the auditory devices on all exit doors were tested and found to be operational.

Fire Extinguishers:
Two fire extinguishers were mounted, fully charged, and serviced on September 13, 2024.

Fire Clearance:
Approved on December 18, 2024 for 5 non-ambulatory and 1 bedridden residents. Please note that only bedridden resident is permitted in bedroom 6 and the bedridden room door shall self-close at all times per inspection report.

Toxins and Sharps:
Cleaning supplies, toxins, and sharps were observed to be secured and inaccessible.

Water Temperature:
The water temperature in the three resident bathrooms measured at 116.9, 115.7, and 117.6 degrees Fahrenheit.

Medications, First Aid Kit, & Manual:
The First Aid Kit was checked and found to be in order.

Component III:


Component III was waived because Applicant is operating other licensed facilities and has fulfilled this requirement.

The Pre-Licensing is now complete, and the facility is ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau.

An exit interview was conducted with Applicant/CEO William Manalo and Administrators Jarren Manalo, BSN, RN and Rhadzivil Baylon, and a copy of this report was provided at the end of the visit.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
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