198603598-12-28-2022-28-AS-CWOG-CMJMYA-20221228090109

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603598
Report Date: 12/20/2022
Date Signed: 12/28/2022 09:02:23 AM

Document Has Been Signed on 12/28/2022 09:02 AM - 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:	ROWLAND HEIGHTS RESIDENTIAL CARE		FACILITY NUMBER:	198603598
ADMINISTRATOR:	SINGH, EILEEN		FACILITY TYPE:	735
ADDRESS:	1404 KINGSMILL AVE		TELEPHONE:	(951) 440-3292
CITY:	ROWLAND HEIGHTS	STATE: CA	ZIP CODE:	91748
CAPACITY: 4		CENSUS: 0	DATE:	12/20/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	02:30 AM
MET WITH:	SINGH, EILEEN		TIME COMPLETED:	04:00 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), Christine Wong, conducted an announced visit to the facility for purpose of a pre-licensing evaluation and met with Administrator Eileen Singh An application was submitted to CCLD on 7/8/2022 , for initial license for an Adult Residential Facility for age range 18 through 49. The requested capacity is for 4 ambulatory only. Structure: Facility is a 4 bedroom, 2 bathroom, living room, dining area, kitchen, single story house with 2 cars attached garage. The client bedrooms are spacious and will easily accommodate the client's furnishings. The passageways, walkways, driveway and patio are free from obstructions. The the front, back and side areas of free of hazards. Bedrooms Residents Bedroom#1 to #4 has one bed, one chair, one night stand, one dresser, closet and one lamp in addition to overhead lighting. Bedrooms Staff: No bedroom designated for awake-staff. Bathrooms: All two bathrooms have a working toilet, wash basin, bath-tub/shower.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

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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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: ROWLAND HEIGHTS RESIDENTIAL CARE	FACILITY NUMBER: 198603598
	VISIT DATE: 12/20/2022

NARRATIVE

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Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in hallway cabinet.

Emergency Phone Numbers, Exit Plan & Menu:
the facilities telephone system is a landline and the phone number is 909-895-7242
Posted & readily available for review on the wall next to dining area.

Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored inside a locked box in the kitchen drawer. Food supply adequate stored in the refrigerator and pantry and consists of the following: two days perishable and seven days non-perishable.

Smoke Detectors:
Electrical & connected. Carbon monoxide detector is mounted on the wall near the entrance and is operational.

Appliances:
The refrigerator in the kitchen, Stove burners, oven, microwave, washer, and dryer are all working properly. Each refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit.

Toxins:
All are Locked/stored in the cabinet in the garage.

Water Temperature:
Tested between 108.6 and 109.2 degrees F.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ROWLAND HEIGHTS RESIDENTIAL CARE	FACILITY NUMBER: 198603598
	VISIT DATE: 12/20/2022

NARRATIVE

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Medications, First-Aid Kit & Book:
A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in the kitchen cabinet, available for staff use but inaccessible to clients. Client's medication will be stored in the hallway cabinet and its locked and inaccessible to clients.

Clients & Staff Files:
Applicant will be handling cash resources of clients and has a surety bond for $3000, cash resources will be locked in the file cabinet next to the kitchen nd stored with P & I Ledger, accessible to designated staff. Records of staff and clients shall be stored in a locked cabinet near the kitchen.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation.

Pool/Jacuzzi & Pets:
There's a swimming pool located in the back yard but its fenced and locked and made inaccessible to clients

Fire clearance:.
Fire Clearance was approved on 8/15/22 with 4 ambulatory capacity

Component III:
Conducted on 12/21/22 via zoom meeting, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

LIC809 (FAS) - (06/04)

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