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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 02:36:00 PM


Document Has Been Signed on 03/24/2023 02:36 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH: Licensee / Hanileta Keohen TIME COMPLETED:
03:10 PM
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 At 9:00am on 03/24/2023, Licensing Program Analysts (LPA') Chavez and Jeffries arrived unannounced at the facility to conduct an annual facility inspection. LPA's met with Licensee, Hanileta Keohen at the door and announced who they were and the reason for the visit. LPA's screened staff currently working at the facility and discovered person working not to be cleared or associated, citation issued on separate case management visit on the different report on this date,

Licensee and LPA's conducted a tour of the facility: This facility is a 3 bedroom and 2 bathroom, with kitchen/office space with a dining room, living room, and large back yard with patio cover and gazebo for residents. LPA's tested smoke alarms and carbon monoxide detectors to be working and in order, LPA's observed two fire extinguishers to be in the green charge and currently tagged for service. LPA's noted that all hallways and exits were free and clear of obstacle and audible alarms on all doors. LPA's observed more than two days of perishable foods and more than seven days of non-perishable foods. LPA's observed resident activities of playing cards, visitation, pet therapy and reading. LPA's tested that water in the facility to be within regulation parameters of 105*- 120* (f). LPA noted the following, no visible violations were noted during the facility tour. The facility is clean and in good repair. No violations or citations were issued as a result of the facility tour. LPA's reviewed medications and Medical Administrator Records (MAR), centrally stored medication records, staff records, and resident records.

Licensee and LPA's conducted annual inspection care tool. There was one technical violation (TV) and one technical assistance (TA) issued as a result of the inspection care tool. The Criminal Record Clearance Regulation 87344 for uncleared staff was issued on a case management dated 03/24/2023, No other citations, violations, or technical were issued during this annual inspection.

Exit interview, report read, report printed and provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
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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