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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801742
Report Date: 06/23/2020
Date Signed: 06/23/2020 03:59:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117
FACILITY NAME:ROYAL HOME CAREFACILITY NUMBER:
405801742
ADMINISTRATOR:HANILETA KEOHENFACILITY TYPE:
740
ADDRESS:729 BOLEN DRIVETELEPHONE:
(805) 238-0128
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 3DATE:
06/23/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:07 PM
MET WITH:HANILETA KEOHENTIME COMPLETED:
03:41 PM
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At 3:07pm Licensing Program Analyst (LPA) Diaz conducted a case management visit at the facility with administrator Hanileta Keohen. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit is being conducted through a tele-visit. The facility evacuated on 6/22/20 due to the River Fire and repopulated the facility on 06/23/2020. LPA toured the facility virtually and observed an adequate food supply and an adequate emergency food supply. The administrator also stated that they have enough PPE supplies. The Administrator did not have an updated emergency disaster plan posted. LPA discussed the emergency disaster plan and provided the administrator with an updated 610E via email. The facility was not impacted by the fire and has no damage. All utilities are functioning. All residents have returned and are resting in the facility.

Exit interview, report given.

SUPERVISOR'S NAME: Alex EstradaTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2020
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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