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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801742
Report Date: 05/13/2022
Date Signed: 05/13/2022 04:40:12 PM


Document Has Been Signed on 05/13/2022 04:40 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



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:
05/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Hanileta Keohen/AdministratorTIME COMPLETED:
12:00 PM
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 At 8:00am on 05/13/2022, Licensing Program Analyst (LPA) Mark Jeffries arrived at the facility, announced who he was and informed Administrator Hanileta Keohen the reason for the visit was annual infection control inspection.
Upon arrival Administrator screen LPA for symptoms and logged visit into facility visitation log. LPA observed screening station with appropriate screening and sanitizing items.LPA observed required postings at entrance to the facility. LPA observed 2 of 2 staff and 3 of 3 residents. LPA and Direct Care Staff (DCS) David Condez conducted a full facility walk through inside the residence and outside the residents. LPA noted that the facility was free of hazards inside and out. LPA observed more than required amounts of food properly stored. LPA observed appropriate amount of PPE stored in the facility garage. The facility has 3 bedrooms and 2 bathrooms. The facility has isolated visitation areas in the kitchen, living room and outside in the back yard with covered patio area. LPA did not discover any deficiencies during the walk through of the facility.
LPA and DCS Condez conducted Infection Control mitigation module with no corrections found in mitigation module.

Exit interview conducted and report signed and provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022
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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