<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800347
Report Date: 05/27/2021
Date Signed: 05/27/2021 11:41:01 AM

Document Has Been Signed on 05/27/2021 11:41 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ROYAL CARE HOMEFACILITY NUMBER:
425800347
ADMINISTRATOR:LEILANIE ACOSTA VEAFACILITY TYPE:
740
ADDRESS:338 EAST CRESTON DRIVETELEPHONE:
(805) 925-9441
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 6CENSUS: 5DATE:
05/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:26 AM
MET WITH:LEILANIE VEA LICENSEETIME COMPLETED:
12:00 PM
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
 At 10:26am, on 05/27/2021, Licensing Program Analysts (LPAs) Arien Diaz and Darlene Chavez conducted an unannounced annual inspection of the facility above. LPAs and administrator toured the facility. LPAs initial tour of the facility resulted in observations which were immediately addressed by the administrator and facility staff: At 10:31am, LPA observed exposed soap under the sink. Administrator, immediately locked soup in the appropriate cabinet. At 10:33 am, LPA observed 2 egresss devices that needed to be turned on or replaced. LPA observed clean counter tops, and adequate food in cabinets and in refrigerator. LPA also observed supply of PPE, toilet paper soap and paper towels.

At 10:43 am, LPA Diaz conducted Infection Control mitigation module with administrator. Administrator had no other corrections found in mitigation module.

Exit interview conducted and report given.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Arien Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1