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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603373
Report Date: 07/21/2023
Date Signed: 07/21/2023 04:48:46 PM

Document Has Been Signed on 07/21/2023 04:48 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 HOME IIFACILITY NUMBER:
198603373
ADMINISTRATOR:PAMELA BOULIGNYFACILITY TYPE:
735
ADDRESS:4739 N. EDENFIELD AVETELEPHONE:
(562) 508-2007
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 4CENSUS: 4DATE:
07/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:07 PM
MET WITH:Jennifer Oglesby - Licensee/AdministratorTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena initiated a Case Management- Deficiencies after it was discovered during the course of the investigation for complaint control # 28-AS-20230628085459 that the facility did not maintain a comfortable temperature in rooms that clients occupy between a minimum of 68 deg F and a maximum of 85 degrees F.

A citation was issued.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit on 7/21/2023 is documented on 809D.

Exit interview held and a copy of the report along with appeal rights were provided to Jennifer Oglesby, Licensee/Administrator.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2023
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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Document Has Been Signed on 07/21/2023 04:48 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/21/2023 at 04:13 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: 07/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2023
Section Cited
CCR
80088(a)(1)(A)

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80088 Furniture, Fixtures, Equipment, and Supplies...(a) A comfortable temperature for clients shall be maintained....(1) The licensee shall maintain the temperature ..... between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C). (A) In areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature.
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Licensee/Administrator shall maintain a comfortable temperature for the clients and agreed to submit a written plan of correction on how to keep the temperature to be maximum 30 degrees F less than the outside temperature and submit plan to LPA/CCL by POC due date.
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This requirement was not met evidenced by:
LPA observed that the temperature in the facility read at 91 deg F which poses a potential health and safety risk to persons in care.
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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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023


LIC809 (FAS) - (06/04)
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