197608164-8-30-2023-28-AS-VMAO-CV7V4H-20230830160622

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608164
Report Date: 08/30/2023
Date Signed: 08/30/2023 04:06:36 PM

Document Has Been Signed on 08/30/2023 04:06 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ROLYN HOME		FACILITY NUMBER:	197608164
ADMINISTRATOR:	RONALD MANALAD		FACILITY TYPE:	740
ADDRESS:	10622 LEEDS STREET		TELEPHONE:	(562) 868-1560
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	6	CENSUS: 4	DATE:	08/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Eadgitha Manala- DSP/Lead Staff		TIME COMPLETED:	04:05 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	Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Care Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA met with Direct Support Professional, Eadgitha Manala and explained the purpose for the visit. The facility is licensed to serve (6) elderly adults, ages 60 and over, of which (4) may be non-ambulatory, and (2) may be ambulatory. The facility is a single-story home, located in a residential area. The home consists of a living room, (4) residents bedrooms, (2) staff rooms, (2) resident bathrooms, a kitchen, dining room, living room, attached garage, and shaded patio with seating in the backyard. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention. During today's visit, LPA Maldonado obtained a copy of the client and staff roster, and conducted a tour of the physical plant with assistance of DSP, Eadgitha Manala. The following was observed: One central entry point for universal entry screening Mitigation Plan and Infection Control Plan approved and in place Sufficient PPE stored for 30-days and readily available for use, throughout the home and stored in the garage Physical plant inside and outside is clean, sanitary and in good repair All walkways and pathways observed to be free of obstruction/hazards All resident rooms inspected had the required furniture, bedding, linens, chair, adequate lighting, & closet space (Report Continued on LIC809-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ROLYN HOME	FACILITY NUMBER: 197608164
	VISIT DATE: 08/30/2023

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
26
27
28
29
30
31
32

Each restroom is equipped with a toilet, shower, and wash basin
Restrooms had the required grab bars and non-skid mats
All kitchen and laundry equipment were clean and operational
Water tested and measured at 114*F in bathroom# 1 and 113.7*F in bathroom# 2, which is in compliance
Food was inspected and was sufficient for residents in care. Requirement met for 2-day perishables and 7-day non-perishables available
One refrigerator inside the home and another freezer in the garage observed fully stocked with a variety of nutritious foods
Kitchen cabinets and garage were observed with a variety of non-perishables including vegetables, proteins, cereals
Emergency disaster plan, personal rights and complaint procedures are posted
Smoke/Carbon monoxide detectors were tested and operating properly
Fire extinguisher observed in the kitchen with a current inspection and was fully charged
Working telephone for clients to use
No bodies of water located on the premises
Adequate seating in common areas for licensed capacity
Cleaning supplies/toxins are stored in a locked under the kitchen sink, inaccessible to clients
Sharps are stored in a kitchen cabinet, locked and inaccessible to clients
(4) Client Files reviewed and observed to be complete with/but not limited to- current health screenings, appraisals, admission's agreements, personal rights, and emergency contact information
(3) Staff files were reviewed and were complete with/but not limited to- fingerprint clearances, health screenings, and proof of required annual training

Due to time constraints, LPA Maldonado was unable to complete the required annual inspection. LPA will return at a later time to complete it.

Per California Code of Regulations, Title 22, no deficiencies were observed during today's visit.

An exit interview was conducted with DSP Eadgitha Manalad, and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2