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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603373
Report Date: 10/07/2022
Date Signed: 10/07/2022 03:46:14 PM

Document Has Been Signed on 10/07/2022 03:46 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:
10/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Andre Hearn, Staff
Pamela Bouligny, administrator		TIME COMPLETED:
04:00 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 met staff, Andre Hearn upon arrival. Administrator, Pamela Bouligny joined the visit 30 minutes later. 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. Administrator certificate is current and expiration date is 9/20/23.

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.

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

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. Adequate linen and personal hygiene supply were observed. Bathrooms were clean and operational.

(-continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2022
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 10/07/2022 03:46 PM - It Cannot Be Edited


Created By: Bonnie Tao On 10/07/2022 at 02:08 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: 10/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:

On 10/7/22, client #2’s morning medication Aripiprazoles 5mg tablet, Atenolol 50mg tablet and Levetiracetam 500 mg tablet weres not taken at 8 am before went to day program. Medication was not dispensed per physician's orders.
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2022
Plan of Correction
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Licensee, Jennifer Howard Oglesby, agreed to provide (1) additional medication administration assistance training to all staff and provide proof of the training to the department; (2) review Title 22, Section 80075(b) and provide a signed statement indicating the review of this section detailing how to prevent future medication errors by the POC date
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: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022


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: RISING HILL DEVELOPMENTAL HOME II
FACILITY NUMBER: 198603373
VISIT DATE: 10/07/2022
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Common areas including the kitchen, living room, and dining room were inspected. Smoke and carbon monoxide detectors were dual, hardwired and in compliance. Fire extinguishers were fully charged and last service was on 3/2/22. First aid kit was fully stocked with manual. The last Fire/ Emergency Drill was conducted on 9/28/22. Comfortable temperature for clients was maintained. Hot water temperature measured at 115.4 degrees Fahrenheit. Hazardous items were locked and inaccessible to clients. There were no firearms on the premises. Dangerous weapons such as knives were locked in the kitchen cabinet.

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. 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 Administrator, Pamela, whose signature on this form confirm receipt of these documents.

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

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC809 (FAS) - (06/04)
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