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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603373
Report Date: 10/18/2021
Date Signed: 10/18/2021 04:20:25 PM

Document Has Been Signed on 10/18/2021 04:20 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:RISING HILL DEVELOPMENTAL HOME IIFACILITY NUMBER:
198603373
ADMINISTRATOR:BOULINGLY, PAMELAFACILITY TYPE:
735
ADDRESS:4739 N. EDENFIELD AVETELEPHONE:
(562) 508-2007
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 4CENSUS: 2DATE:
10/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jennifer Oglesby (Howard), Licensee
Eric Howard, Staff		TIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tao, conducted an unannounced annual inspection. The facility has a capacity of four (4). The facility is licensed to serve four (4) ambulatory, age 18-59 clients. Client census is two (2). LPA was allowed entry by Licensee, Jennifer Oglesby (Howard). San Gabriel Pomona Regional Center provides case management service to client residing in this home. Facility annual fees are current. LPA discussed the purpose of today's visit.

During the visit, the following domain of the new inspection tool was used: infection control domain; a tour of the facility conducted; food supply was reviewed; and medications were reviewed.

LPA toured the facility inside and outside with Licensee. The facility was a single-story home consisted of three (3) client’s bedrooms, one (1) bathroom, a kitchen, a dining room, a living room, an administration office, and a detached garage with laundry area. The home is located in a residential neighborhood within the city of Covina.

The kitchen is clean and has maintained the required two (2) days perishable and seven (7) days non- perishable. All burners and stove tops were in working condition. Clients’ bedrooms have beds, dressers, chairs and closet space available. Lamps/lights for each room were available to ensure the safety and comfort of all persons in the facility.
(-continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2021
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: RISING HILL DEVELOPMENTAL HOME II
FACILITY NUMBER: 198603373
VISIT DATE: 10/18/2021
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Adequate linen and personal hygiene supply were observed. Bathrooms were clean and operational.

LPA also inspected facility common areas including the kitchen, living room, and dining room. Smoke and carbon monoxide detectors were dual, hardwired and in compliance. Fire extinguishers were fully charged. First aid kit was fully stocked with manual. The last Fire/ Emergency Drill was conducted on June 22, 2021. Hazardous items were locked and inaccessible to clients. Administrator certificate was current with expiration date on July 1, 2023. There were no firearms on the premises and other dangerous weapons such as knives were locked in the kitchen cabinet. Comfortable temperature for clients was maintained. Hot water temperature measured at 115 degrees Fahrenheit.

Pesticides/poisons were not stored in food areas, kitchen, or where kitchen equipment/utensils were stored.

Medications were centrally stored and locked in a cabinet. Medications were properly logged and current. Hazardous items were locked and inaccessible to clients.

Deficiencies were cited per California Code of Regulations, Title 22, Division 6.

An exit interview was conducted. This report is discussed and provided to Licensee, whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/18/2021 04:20 PM - It Cannot Be Edited


Created By: Bonnie Tao On 10/18/2021 at 03:49 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: RISING HILL DEVELOPMENTAL HOME II
FACILITY NUMBER: 198603373

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Buildings and Grounds (a)
The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, ...

This requirement is not met as evidenced by:
Client room#3’s back door has broken glasses and side gate was broke.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2021
Plan of Correction
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Licensee will ensure the broken glass on Client Room #3's back door be replaced or the back door will be replaced with a new door. Licensee will ensure the side gate be repaired. Plan of Corrections (POC) must be corrected by POC.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2021


LIC809 (FAS) - (06/04)
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