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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801742
Report Date: 03/24/2023
Date Signed: 03/24/2023 01:47:11 PM


Document Has Been Signed on 03/24/2023 01:47 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: 4DATE:
03/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Hanileta Keohen, LicenseeTIME COMPLETED:
03:00 PM
NARRATIVE
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On 3/24/2023 at 9:00 am, Licensing Program Analysts (LPAs) Darlene Chavez and Mark Jeffries arrived at the facility to conduct an unannounced annual inspection. LPAs met with Hanileta Keohen, Licensee, and explained the reason for the visit.

During the facility tour, LPAs determined that Staff #1 (S1) was not associated to the facility and working with residents in care. At 9:07 am, LPAs confirmed S1’s identity. Licensee says that S1 was only working in the facility today. LPA Jeffries informed licensee that S1 must have a criminal background clearance prior to S1 working with residents in care.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Civil penalties assessed in the amount of $100.



Exit interview conducted, deficiency cited and the report, civil penalties, and appeal rights given to the licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
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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Document Has Been Signed on 03/24/2023 01:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ROYAL HOME CARE
FACILITY NUMBER: 405801742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/27/2023
Section Cited

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87355(e)(1) Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as evidenced by:
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The licensee immediately dismissed S1. Licensee will review the regulation cited and write an acknowledgement of understanding of the regulation.
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Based on observations, the licensee employed S1 who does not have a criminal record clearance and was working in the facility which poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2