198600622-12-12-2023-28-AS-CWOG-CYFSHM-20231212125345

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600622
Report Date: 12/12/2023
Date Signed: 12/12/2023 12:54:27 PM

Document Has Been Signed on 12/12/2023 12:54 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	R N R HOME		FACILITY NUMBER:	198600622
ADMINISTRATOR:	REICHENBERGER, REBECCA		FACILITY TYPE:	735
ADDRESS:	1619 SEKIO AVENUE		TELEPHONE:	(909) 594-6153
CITY:	ROWLAND HEIGHTS	STATE: CA	ZIP CODE:	91748
CAPACITY: 6		CENSUS: 4	DATE:	12/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Rebecca Reichenberger		TIME COMPLETED:	01:15 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) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with DSP Dolores Ugaban and explained the reason of the visit. Later on, the facility administrator Rebecca Reichenberger arrived and assisted with the visit. The facility is approved for serve for six (6) ambulatory Developmentally Disabled Adults ages 18-59. The facility is licensed as a Level 2 home vendored by San Gabriel Pomona Regional Center. The following twelve (12) tool domains were observed and reviewed: Infection Control, Physical Plant/Environmental Safety, Operational Requirements, Staffing, Personal Records-Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness and Emergency Intervention. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing. The facility has an Infection Control Plan and COVID-19 mitigation plan in place. 2.Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: living room, dining area, family room, kitchen, three clients bedrooms, one client bathroom and one live in staff bedroom and bathroom and an attached garage. Each clients' bedrooms has two beds, two chairs, two night stands, required furniture and beddings and sufficient lighting and closet space. The client bathroom is clean, sanitary and in a good working condition. The hot water temperature tested in a client bathroom was 118.7 which is within the Title 22 regulation. (See LIC 809 Continuation)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: R N R HOME	FACILITY NUMBER: 198600622
	VISIT DATE: 12/12/2023

NARRATIVE

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All the appliances in the kitchen and living room is working properly. The sharp knives and utensils are stored and locked under the sink. All the cleaning supplies and chemicals are stored and locked in the cabinet near the entrance door. The extra linen and personal hygiene products are stored in the hallway cabinet. The hallway night will always on during night time for client to access the non-private bathroom. The facility has a land line telephone system for client to use. The passageway, walkway and patio are free of obstruction. LPA inspected the carbon monoxide detectors and it's mounted on the wall near the family room and its working well. LPA also inspected the smoke detectors and its located in each client bedrooms and common area and they are working properly.

3. Operational Requirement: The facility is licensed for six (6) ambulatory only. Currently all four clients in the facility are ambulatory. The facility patio has a shaded area with table and chairs for client to use for outdoor activity. The client also has an opportunity to attend the community activities if needed. The last fire drill was conducted on 11/22/23.

4. Staffing: The facility has sufficient staffing in the facility. LPA reviewed the NOC Shift staff and has the required the facility planned emergency procedure training.

5. Personnel Records-Training: The facility staff files are stored in the cabinet in the living room. All staff are over 18 years old, fingerprint cleared and associated with the facility. LPA reviewed three (3) staff files and all staff files have the required documents included: Health screenings, TB test result, required training hours and updated First Aid Certificate/CPR. The facility Administrator is Rebecca Reichenberger and her administrator certificate is expired on 09/09/23 and currently is pending with the CCL system since 08/24/23. The administrator has the updated HIV and TB Training certificate and dated on 6/9/23.

6. Client's Right-Information: Currently no clients in the facility required any postural support.

7. Client's Record-Incident Reports: All the clients files are stored in the cabinet in the living room. LPA reviewed all four (4) clients' files and they all have the required documents including: face sheet, admission agreement, updated physician report, TB test result, functional capabilities assessment, Individual Program Plan (IPP), ambulatory status and medication list.
(See LIC 809C for continuation)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: R N R HOME	FACILITY NUMBER: 198600622
	VISIT DATE: 12/12/2023

NARRATIVE

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8. Food Service: The facility has ample supply of 2 days perishable and 7 days non-perishable food supply. Currently no client is on any modified diet. All the food in the facility are stored properly.

9. Health Related Services : The facility staff assists clients with their dental and medical appointment and provide transportation for them. The client's medication is centrally stored and locked in a cabinet next to the dining area. LPA inspected all four (4) clients medication and they seemed accurate and updated. All clients have 30 days supply of medication.

10. Incidental Medical and Dental Services: Currently the facility has no client on any restricted health condition care plan and they do not have any clients that are with prohibited health condition.

11. Disaster Preparedness: The facility has an updated emergency disaster plan LIC610D dated on 12/12/23. The last fire drill was conducted on 11/22/23. The facility does have two alternative temporary shelter location.

12. Emergency Intervention: The facility does not use any restraints on clients.

No deficiencies were observed during the annual visit.

Exit interview conducted with Administrator Rebecca Reichenberger and a copy of this report is being provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC809 (FAS) - (06/04)

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