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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608164
Report Date: 07/16/2024
Date Signed: 07/16/2024 03:57:30 PM


Document Has Been Signed on 07/16/2024 03:57 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:ROLYN HOMEFACILITY NUMBER:
197608164
ADMINISTRATOR:RONALD MANALADFACILITY TYPE:
740
ADDRESS:10622 LEEDS STREETTELEPHONE:
(562) 868-1560
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY:6CENSUS: 4DATE:
07/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Eadgitha Manalad, StaffTIME COMPLETED:
04:05 PM
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Licensing Program Analysts (LPAs) Daniel Konishi and Christine Wong, conducted a required unannounced annual inspection using the Inspection Tool. LPA met with Staff#1 (S1), Eadgitha Manalad and the purpose of the visit was discussed. S1 assisted in the tour of the facility.

The following (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Resident Rights/Information, and Food Service.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA observed that the facility has no infection control plan in place.


Physical Plant/Environment Safety:

· LPA conducted a tour of the facility with S1, staff and observed the following:


The facility is part of a single-story home located in a residential area and contains the following: living room, TV room, dining room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, (4) resident rooms, (2) bathroom for residents, toilet and washbasin. A back yard with shaded area and seating for resident use. There’s a laundry area; with washer and dryer.
· All passageways, walkways, driveway, steps and patio are free from obstructions. The front, back and side areas of the house are free of hazards.
· Hallway linen closet: Contained plenty of linens, towels, and hygiene products.

· Beds have the required furniture including bedframes, night stands, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Daniel KonishiTELEPHONE: 323-981-3978
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ROLYN HOME
FACILITY NUMBER: 197608164
VISIT DATE: 07/16/2024
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· Fire extinguisher was observed on hallway last reviewed 04/10/2024.

· Carbon monoxide detectors are tested and in working condition.

· Cleaning supplies are kept locked under kitchen sink away from food supplies.

· Sharps are kept locked in a kitchen drawer.

· Shared client bathrooms were observed to be clean and contained soap and paper towels. Signs promoting hand washing were observed. Water temperature in this bathroom#1 was measured at 108.1 degrees F and Bathroom #2 was measured at 107.9 degrees F which is in the required 105 – 120 degrees F per Title 22 Regulations.

Operational Requirements:


· Fire clearance was approved by LA County Fire Department for six (6) residents, four (4) of which can be non-ambulatory.
· Liability Insurance is confirmed and currently on file.

Resident Rights/Information:
· Residential Care Facility for the Elderly Complaint Poster (PUB 475) posted on the wall.
· Residents’ Personal Rights posted on the wall.
· Facility provides internet access for residents.

Food Service:
· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Due to time constraints, LPA will return at a later date to complete 7 more CARE Tool domains. Exit interview conducted with Staff, Eadgitha Manalad and a copy of this report was provided.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Daniel KonishiTELEPHONE: 323-981-3978
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC809 (FAS) - (06/04)
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