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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603141
Report Date: 06/17/2023
Date Signed: 06/19/2023 12:55:13 PM

Document Has Been Signed on 06/19/2023 12:55 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:RISING HILL DEVELOPMENTAL HOMEFACILITY NUMBER:
198603141
ADMINISTRATOR:LEWIS, FELISHAFACILITY TYPE:
735
ADDRESS:1 RISING HILL RDTELEPHONE:
(909) 417-5505
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 4CENSUS: 3DATE:
06/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Licensee Jennifer OglesbyTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 06/17/2023 at 8:45 am. LPA was met by Staff #1 (S1) and explained the purpose of the visit. S1 assisted in tour of facility. Administrator Pamela D.Bouligny arrived later to the facility. There are three (3) level 4I developmentally disabled clients in the home. The facility is licensed for clients 18-59 years old. The facility has a fire clearance approved for four (4) ambulatory. All clients receive services from San Gabriel Pomona Regional Center. LPA requested and obtained a copy of Personnel Report, and Resident Roster.

LPA OBSERVATIONS: Tour began at 9:02 am and was led by S1. The facility is a single-story building located in a residential area with three (3) client bedrooms, two (2) bathrooms, kitchen, dining room, front yard, backyard, and attached garage.

· Front Yard: Was clean and well maintained. No hazards were observed.

· Kitchen: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA observed knives and sharps located in nearby cabinet to be inaccessible to 3 out of 3 clients in care. LPA observed several bottles of cleaning solutions and disinfectants under kitchen sink cabinet to be inaccessible to 3 out of 3 clients in care.

· Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed plenty of seating and lighting.

· Linen Closet: Contained plenty linens, towels, and hygiene products.

· Resident Rooms 1 - 3: All contained the required furnishings, lighting and linens. Bedrooms were observed to be clean with plenty of closet space. All bedrooms are currently private.

· Bathrooms: Shared client bathroom# 1 was observed to be clean and contained soap and paper towels. Signs promoting hand washing were observed. Water temperature in this bathroom was measured at 106.7 degrees F which is in the required 105 – 120 degrees F. Private bathroom #2 was observed to be clean and water temperature was measured at 109.4 degrees F.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: RISING HILL DEVELOPMENTAL HOME
FACILITY NUMBER: 198603141
VISIT DATE: 06/17/2023
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· Centrally Stored Medications: LPA observed cabinet located in hallway to be locked and inaccessible to residents. LPA reviewed 3 client medications and Medication Administration Record (MAR).

· Backyard: Clean and free from hazards. LPA observed plenty of seating and shade. No large bodies of water were observed.

LPA observed carbon monoxide in hallways. Smoke detector is hard wired and tested during visit. Administrator certificate was observed for Pamela D. Bouligny with an expiration date of 09/20/23. Last fire drill was conducted on 05/04/23. First Aid kit was inspected. 3 out of 3 clients records were reviewed. Staff files were reviewed.

No deficiencies are being cited during visit. Exit interview was conducted with Licensee Jennifer Olesby and a copy of this report was provided via email due to printer problems.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2023
LIC809 (FAS) - (06/04)
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