<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802391
Report Date: 02/02/2022
Date Signed: 02/02/2022 05:31:54 PM

Document Has Been Signed on 02/02/2022 05:31 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:RIMGROVE RESIDENTIAL CAREFACILITY NUMBER:
197802391
ADMINISTRATOR:LEE FRANCES PORTERFACILITY TYPE:
735
ADDRESS:619 RIMGROVE DRIVETELEPHONE:
(626) 336-2343
CITY:VALINDASTATE: CAZIP CODE:
91744
CAPACITY: 4CENSUS: 4DATE:
02/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ambrose MetuTIME COMPLETED:
01:00 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) Christine Wong conducted an annual required visit. LPA met with DSP Ambrose Metu and explained the reason for the visit and assisted LPA with the tour of the visit. LPA spoke with the administrator Angela Porter on the phone. LPA used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures and observed food supply Facility has submitted a mitigation plan and was approved on 05/15/2021

The facility is a one story house and located in a residential neighborhood area. The facility included kitchen, dining room, living room, four clients bedrooms, two bathrooms and an attached garage. All 4 clients bedrooms were toured. Each bedroom has one bed, one chair, closet , required linen, dresser and sufficient light. All 2 bathrooms were toured and they are operational, clean, sanitary and free of odors. At 12:00pm, the hot water temperature for both bathrooms were measured at 124.8 degrees which is beyond the required 105 - 120 degrees. The refrigerator and pantry in the kitchen has sufficient two days perishable and seven days non perishable food. All the appliances are clean and working properly. The common areas such as living room and dining room are clean and have the required furniture. The front and back yard are maintained well. The front yard has a shaded area and sitting area for clients and visitors to use. LPA also inspected the smoke detectors and carbon monoxide detectors and they are operational.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in each room and facility is disinfected every shift or as needed, the bathrooms have sufficient soap, paper towels, and signs and PPE supplies are stored for 30 days.

The deficiencies cited are documented on the attached 809D. A copy of the report and appeal rights will be provided to DSP Ambrose Metu
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2022
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
Document Has Been Signed on 02/02/2022 05:31 PM - It Cannot Be Edited


Created By: Christine Wong On 02/02/2022 at 12:25 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: RIMGROVE RESIDENTIAL CARE
FACILITY NUMBER: 197802391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
80088(e)(1) Furniture,Fixtures, Equipment and Supplies (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation , LPA measured both bathrooms hot water temperature was tested 124.8 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2022
Plan of Correction
1
2
3
4
The administrator will fix the hot water temperature immediately and will send the 7 days hot water log to LPA via email and esure the hot water temperature maintain between 105 and 120 degrees F.
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.
SUPERVISOR'S NAME:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2