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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608164
Report Date: 07/03/2026
Date Signed: 07/03/2026 05:34:51 PM

Document Has Been Signed on 07/03/2026 05:34 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/
DIRECTOR:		RONALD MANALADFACILITY TYPE:
740
ADDRESS:10622 LEEDS STREETTELEPHONE:
(562) 868-1560
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 6CENSUS: 4DATE:
07/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:57 AM
MET WITH:House Manager-Eadgitha ManaladTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA)Elena Mallett conducted an unannounced visit to the facility to conduct an Annual Visit. LPA met with House Manager Eadgitha Manalad and explained the purpose for today’s visit. House Manager contacted Administrator Ronald Manalad on the phone and LPA spoke with Administrator about the visit. The facility is licensed to serve developmentally disabled adults 4 Non-Ambulatory Residents and 2 ambulatory residents ages 60 and above. Residents receive services from the Harbor Regional Center.

The facility is a single-story home located in a residential area in Norwalk, CA. A tour of the facility includes: 4 resident bedrooms, 2 bathrooms, 2 staff bedrooms, kitchen, dining area, living room, front yard and back yard and detached garage.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today's visit observed the following:

Infection Control: Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility. Facility has a designated Infection control lead.

Operational Requirements: The facility maintains the required liability insurance and Surety Bond. The facility has a fire clearance. LPA observed P & I Ledgers for all the residents who received P& I and no issues were observed.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2026
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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Document Has Been Signed on 07/03/2026 05:34 PM - It Cannot Be Edited


Created By: Elena Mallett On 07/03/2026 at 03:26 PM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ROLYN HOME
FACILITY NUMBER: 197608164

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(5)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101, Definitions, or bedridden as defined in Health and Safety Code section 1569.72. The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition, or both.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1out of 4 residents ( R1) did not have a Physcian's Report in their file that contained a designation of ambulatory status. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2026
Plan of Correction
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By POC due date Administrator send to office Fax a Physician's Report for R1 which includes R1's ambulatory status.
Type B
Section Cited
CCR
87305(a)

87305 Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that two staff rooms were added to the physcial plant without obtaining permits for the rooms'construction which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2026
Plan of Correction
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By POC due date Administrator will fax to office fax permits from the City of Norwalk for the two staff rooms that were constructed. Administrator will fax a letter of support from Regional Center for the changes made to the physical plant.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2026 05:34 PM - It Cannot Be Edited


Created By: Elena Mallett On 07/03/2026 at 04:21 PM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ROLYN HOME
FACILITY NUMBER: 197608164

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(c)
87307 Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:
(C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that residents and staff utilize the restroom located inside a resident's private bedroom ( Bedroom 4) on a regular basis which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2026
Plan of Correction
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By POC due date Administrator will fax to the office fax a signed statement of understanding of the above regulation to LPA and abide by the regulation.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2026


LIC809 (FAS) - (06/04)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ROLYN HOME
FACILITY NUMBER: 197608164
VISIT DATE: 07/03/2026
NARRATIVE
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Physical Plant & Environment Safety: LPA toured facility. The facility is well maintained and walkways and hallways are free of debris and obstruction. Residents’ bedrooms were checked and contained the required furnishings and sufficient closet/drawer space to accommodate each resident comfortably. Sufficient light, towels and bed linens were observed. The backyard is free of debris/hazards and the outdoor and indoor passageways are free of obstruction. No bodies of water were observed at the facility. A shaded table and outdoor furniture were present to allow the residents to enjoy the outdoors. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was measured in both bathroom faucets and was measured within Title 22 requirements of 105 degrees F- 120. Grab bars and non slip floor material was observed. Smoke detectors were observed in the hallway and in each resident's room. Smoke detectors and a carbon monoxide detector were tested and observed to be functional. There was a fire extinguisher present that was observed to be fully charged. All storage areas for cleaning solutions, toxins, knives, sharps and hazardous items are kept locked and inaccessible to residents

LPA observed that a bathroom located in a resident's private room was being utilized by staff and other residents. A deficiency was cited. See 809-D

LPA observed that two staff bedrooms that did not appear on the facility sketch were present. Per Administrator these staff bedrooms had been constructed from the existing living room and did not require building permits. Administrator did not provide LPA with proof that the bedroom construction did not require building permits. A deficiency was cited. See 809-D. LPA observed that the constructed staff bedrooms did not contain smoke detectors and only one bedroom contained windows.

Staffing: There appears to be sufficient staffing at all times in the facility. The night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency.

Personnel Records-Training: Staff files are kept in a secure location. LPA reviewed 5 staff files. Files were reviewed for Criminal Record Clearance, Health Screening and Current First Aid and initial and ongoing training for care of the Elderly. No issues were observed. Administrator’s certificate is current until 09/10/27.

Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Medical Consent, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 4 Resident Files and a deficiency was observed. See 809-D. House Manager was advised to document inventory of resident personal items.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2026
LIC809 (FAS) - (06/04)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ROLYN HOME
FACILITY NUMBER: 197608164
VISIT DATE: 07/03/2026
NARRATIVE
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Residents Rights-Information: Residents are provided with telephone and internet at the facility. All the required postings were observed.

Planned Activities: Facility offers activities like crafts, trips to the mall, to church, to the park and out to eat. There is a central TV viewing area for residents to enjoy together. There is an outdoor furnished patio area available for the residents. An activity calendar was observed.

Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Food was stored separately from cleaners, toxins and poisons. Appliances were observed to be operable and able to properly store and prepare food.

Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a locked closet and are in their original containers. LPA reviewed 4 residents’ medications and there were no issues observed.

Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Emergency food and water were observed. Disaster food and water was observed. A full First Aid kit and Manual were available. The facility does quarterly disaster drills but was overdue for second quarter drill with the last drill being conducted in January 2026. A technical violation was given.

Residents with Special Health Needs: No residents at the facility have special health needs.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit are documented on the 809(D).

Exit interview was held with House Manager Eadgitha Manalad and a copy of this Licensing report was provided along with Appeal Rights.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2026
LIC809 (FAS) - (06/04)
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