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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425396
Report Date: 09/21/2022
Date Signed: 09/21/2022 10:55:13 AM

Document Has Been Signed on 09/21/2022 10:55 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:ROYAL PALMS GUEST HOMEFACILITY NUMBER:
336425396
ADMINISTRATOR:ARNALINA JAUDALSOFACILITY TYPE:
740
ADDRESS:6943 GYPSUM CREEK DRVTELEPHONE:
(951) 427-3516
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 6CENSUS: 4DATE:
09/21/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Marco Pascaran, CaregiverTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Amy Goldenberg is conducting this unannounced visit to the facility for the purposes of a Plan of Correction (POC) visit, based upon the deficiencies cited on LIC form 809D on 09/20/2022. During this visit LPA toured the facility and gained access to a bedroom that was found locked and inaccessible during the annual inspection conducted on 09/20/2022. There were no additional deficiencies observed as a result of this visit.

*Deficiency 87755 (a) cited per Title 22 Division 6 of the California Code of Regulations has been cleared. Licensee complied with the terms of the POC.

This report was reviewed with and a copy provided to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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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