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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600622
Report Date: 07/13/2022
Date Signed: 07/14/2022 09:29:32 AM

Document Has Been Signed on 07/14/2022 09:29 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:R N R HOMEFACILITY NUMBER:
198600622
ADMINISTRATOR:REICHENBERGER, REBECCAFACILITY TYPE:
735
ADDRESS:1619 SEKIO AVENUETELEPHONE:
(909) 594-6153
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 6CENSUS: 4DATE:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:05 AM
MET WITH:Mediatrix Calabig-Administrator TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with the administrator Mediatrix Calabig and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed client and staff files.

The facility is a single story house and located in a neighborhood area. The facility consists of living room, dining area, TV room/Family room, three clients bedrooms, two bathrooms, live in staff bedroom and a attached garage. All 3 clients bedrooms were toured. Each bedroom has two beds, two dresser, required bed linen and furniture and sufficient lighting and closet space. The two bathrooms were toured and they are clean, sanitary and in a good working condition. The hot water temperature at two bathrooms were measured at 100.8 and 101 degrees and is blow the required 105-120 degrees F. The refrigerator and kitchen cabinet and storage room has sufficient for two days perishable and seven days non perishable food. The appliance in the kitchen are working properly. The knives and sharp utensils are locked under the sink. The common area such as living room, TV room or dining area are clean and have the require furniture. The front and back yard are maintained well and the back yard has shaded area and sitting area for clients to utilize. The chemicals and cleaning supplies are locked under the sink and inaccessible to clients.

LPA reviewed all four clients emergency contact information and they are updated in their chart. LPA also reviewed staff file for fingerprint clearances and health screening and its updated on the staff file. LPA also reviewed 3 clients medication and they are all seemed accurate and updated.

See LIC 809C for continuation.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2022
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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Document Has Been Signed on 07/14/2022 09:29 AM - It Cannot Be Edited


Created By: Christine Wong On 07/13/2022 at 04:13 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: R N R HOME
FACILITY NUMBER: 198600622

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
82088 Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care shall deliver hot water.
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures 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
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Based on LPA's observation, the hot water temperature tested at the two bathrooms are between 100.8 and 101.1 degrees which is below the required 105 and 120 degrees F. which posed an immedate risk to clients in care
POC Due Date: 07/14/2022
Plan of Correction
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The administrator will ensure the hot water temperature of not less than 105 degrees F and not more than 120 degrees F and fax the hot water temperature immediately and send the seven days daily hot water log to LPA by 7/20/22
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.
SUPERVISOR'S NAME:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022


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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: R N R HOME
FACILITY NUMBER: 198600622
VISIT DATE: 07/13/2022
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in common area and facility is disinfected every hours, the bathrooms have sufficient soap, paper towels, and signs, facility has an isolation room and a cart with PPE supplies, and PPE supplies are sufficient for 30 days.

The following deficiencies are being cited on the attached LIC 809D page, California Code of Regulations, Title 22, Division 6, Chapter 1.

Exit interview conducted with Administrator Mediatrix Calabig and a copy of this report is being provided and Appeal Rights were given.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC809 (FAS) - (06/04)
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