405801742-4-24-2026-29-AS-GHTO-DSWQSV-20260407122609

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801742
Report Date: 04/07/2026
Date Signed: 04/24/2026 09:50:07 AM

Document Has Been Signed on 04/24/2026 09:50 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 CARE		FACILITY NUMBER:	405801742
ADMINISTRATOR/ DIRECTOR:	HANILETA KEOHEN		FACILITY TYPE:	740
ADDRESS:	729 BOLEN DRIVE		TELEPHONE:	(805) 238-0128
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY: 6		CENSUS: 4	DATE:	04/07/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:13 AM
MET WITH:	Licensee/Administrator - Hanileta Keohen		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 9:13am, on 4/7/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Licensee/Administrator Hanileta Keohen, announced who he was and the reason for the visit. Licensee and LPA conducted a full tour of the facility. This facility is a single story residential home with three resident bedrooms (one is dual occupancy), two full bathrooms (one is en-suite and one is for public use). There is a living room with dining space, a kitchen and office area. The living room has a fireplace with barrier for resident protection and a piano for residents or visitors to play. Access to the laundry area and garage is through a locked door for resident safety. LPA noted that the backyard has seating and shade for residents and visitors. LPA noted fresh fruit and snacks in the kitchen for residents to enjoy. The facility has battery operated smoke detectors in each room that are all working, the carbon monoxide detector is in the living room and functioning normally. LPA observed a fire extinguisher near the kitchen that was tagged current and in the green compression range, serviced on 10/29/2025. LPA tested facility hot water at 120°F, within regulation temperatures 105-120°F. LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. LPA noted that the facility is in good repair with no obstructions in hallways, doorways or exits. Medications are locked in a cabinet in the kitchen area. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records, finding no violations. Staff and client files are in the enclave of the kitchen. LPA conducted a staff and resident file review. (Continued LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 405801742
	VISIT DATE: 04/07/2026

NARRATIVE

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LPA noted 1 of 4 residents medical assessments indicate they are at risk if given access to poisonous substances and sharp objects. During facility tour at 9:31am LPA and licensee noted on the back patio on a metal rack covered with a tablecloth a box of plant food, aerosol can of bug spray, bottle of mosquito repellent, one quarter full bottle of Windex, and a kitchen knife approximately six inches in length with a black handle, all not locked up. Under the awning covered patio not connected to the house, in the backyard a wooden sink cabinet with two gardening pruners, two scissors, and aerosol false plant cleaner not locked up. Between the separate awning and the wall along the north side of the of the backyard a half full bottle of bug spray not locked up. All of these items were unattended and accessible to residents in care. Licensee locked up the items upon discovery. Unlocked and accessible poisonous substances was cited during last years facility annual conducted on 5/21/2025.

LPA and Licensee conducted a review of the annual care tool modules.

Exit interview conducted, deficiency cited on LIC809-D page, a civil penalty for in the amount of $250 for a repeat violation within the last 12 months is being assessed on the attached LIC421FC, report signed, report and appeal rights provided to Licensee.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/24/2026 09:50 AM - It Cannot Be Edited

Created By: Garrett Haner-Tomasko On 04/07/2026 at 11:50 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYAL HOME CARE	FACILITY NUMBER: 405801742
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above when they left poisonous substances and sharp objects unlocked and unattended , accessible to residents which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 04/21/2026
	Plan of Correction
1 2 3 4	Licensee states they will find a course through a CCLD approved vendor regarding locked storage of hazardous items and have all staff including themself take the course and submit the certificates of completion for each staff to the LPA on or before 4/21/2026.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:

	Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026

LIC809 (FAS) - (06/04)

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