<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603373
Report Date: 10/23/2023
Date Signed: 10/23/2023 04:06:22 PM

Document Has Been Signed on 10/23/2023 04:06 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:PAMELA BOULIGNYFACILITY TYPE:
735
ADDRESS:4739 N. EDENFIELD AVETELEPHONE:
(562) 508-2007
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 4CENSUS: 2DATE:
10/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Jennifer Oglesby, LicenseeTIME COMPLETED:
04:20 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) 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 with Administrator, Jennifer Oglesby. 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, CARE tool was used, a tour of the facility conducted, staff/clients records were reviewed, 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. Clients’ bedrooms had the required furnishing and in compliance. Bathrooms were clean and operational. Common areas including the kitchen, living room, and dining room were inspected. Smoke and carbon monoxide detectors were dual, hardwired and in compliance. The last Fire/ Emergency Drill was conducted on 9/9/23. Hot water temperature measured at 105.4 degrees Fahrenheit. Hazardous items were locked and inaccessible to clients. Medications were centrally stored and locked in a cabinet. Medications were properly logged. Hazardous items were locked and inaccessible to clients.

No deficiencies were cited per California Code of Regulations, Title 22, Division 6. An exit interview was conducted. LIC 809 was provided to Administrator, Jennifer
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2023
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 1