425800347-5-23-2024-29-AS-MRAN-D5JSRM-20240523140636

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425800347
Report Date: 05/23/2024
Date Signed: 05/23/2024 02:11:25 PM

Document Has Been Signed on 05/23/2024 02:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ROYAL CARE HOME		FACILITY NUMBER:	425800347
ADMINISTRATOR/ DIRECTOR:	LEILANIE ACOSTA VEA		FACILITY TYPE:	740
ADDRESS:	338 EAST CRESTON DRIVE		TELEPHONE:	(805) 925-9441
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY: 6		CENSUS: 4	DATE:	05/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Leilanie Acosta Vea		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

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Licensing Program Analyst (LPA) Melisa Rankin arrived at 09:45am to conduct a 1-year annual visit. LPA met with Leilanie Acosta Vea and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted with Administrator, Leilanie Acosta Vea. The following was inspected and noted during the annual visit:

The facility has 3 bathrooms and 6 bedrooms, one of which is being used as an office and another which is located on the fire clearance as a “Manager room” in the garage. The common areas for residents are clean, safe and sanitary. The facility has smoke and carbon monoxide detectors. Carbon Monoxide and 2 smoke alarms were tested and working at the time of visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard and a front yard area for client use with furniture and plenty of shade. The facility has telephone and internet service for resident use. The backyard has 2 sheds which are secured.

The Facility is operating in compliance with the granted fire clearance and facility sketch. The facility has current liability insurance which expires on 05/17/2025. The facility is approved for a capacity of 5 non-ambulatory and approved for hospice waiver of 1.

Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYAL CARE HOME	FACILITY NUMBER: 425800347
	VISIT DATE: 05/23/2024

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The facility has 2 full-time staff, one of which is the Administrator, and 2 back-up staff. Staff records are kept confidential. LPA reviewed 3 staff files. Files reviewed had all required information. All staff have current CPR/First Aid training. Administrator training document was reviewed for Continuing Education requirements and an Administrator Certificate was submitted to Licensing in October of 2023. LPA reviewed 3 staff training records for Annual Training Requirements. Training records are kept on file, additional certificates are needed and are scheduled to be completed in the next 14 days.

Four (4) resident files were reviewed and all have required paperwork as well as the necessary annual assessments for dementia/mild cognitive residents.

The facility has medication locked in office area. The medication records were reviewed and medication audit was conducted. All residents in care had a Centrally Stored Medication Destruction Record that was up to date and accurate.

The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. All food is covered, stored and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, and insects. LPA observed a meal preparation and meal service.

The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguisher was charged. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

The facility does accept dementia residents in care. Additional locks will be added for locations where potential cleaners could be stored. The facility does not have delayed egress. The facility does not currently have residents with oxygen. The backyard is completely fenced with a self-latching/self-closing gate.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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