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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801742
Report Date: 05/01/2024
Date Signed: 05/01/2024 11:25:08 AM


Document Has Been Signed on 05/01/2024 11:25 AM - 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 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:
05/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:23 AM
MET WITH:Hanileta "Annie" KeohenTIME COMPLETED:
12:00 PM
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 At 8:23 am on 05/1/2024, Licensing Program Analysts (LPA') Rankin and Jeffries arrived unannounced at the facility to conduct an annual facility inspection. LPA's met with Licensee, Hanileta Keohen and Lead Caregiver Dave Condez at the door and announced who they were and the reason for the visit.

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 one fire extinguisher 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 tested that water in the facility to be within regulation parameters of 105*- 120* (f).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 using the care tool. No violations were cited.

Exit interview, report read, report printed and provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
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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