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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603598
Report Date: 12/19/2023
Date Signed: 12/19/2023 10:11:05 AM

Document Has Been Signed on 12/19/2023 10:11 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 CAREFACILITY NUMBER:
198603598
ADMINISTRATOR:SINGH, EILEENFACILITY TYPE:
735
ADDRESS:1404 KINGSMILL AVETELEPHONE:
(951) 440-3292
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 4CENSUS: 0DATE:
12/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Eileen SinghTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with the administrator Eileen Singh and explained the reason of the visit. The facility is approved for AGE RANGE 18 THROUGH 59. APPROVED FOR FOUR (4) AMBULATORY. Currently the facility has no client in the facility.

The following twelve (12) tool domains were observed and reviewed: Infection Control, Physical Plant/Environmental Safety, Operational Requirements, Staffing, Personal Records-Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness and Emergency Intervention.

1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has an Infection Control Plan and COVID-19 mitigation plan in place.

2. Physical Plant and Environmental: The facility is a single story house and located in a residential neighborhood area. The facility includes: living room, dining area, kitchen, four clients bedroom, two clients bathrooms and an attached garage. Each client bedroom has one bed, one chair, one night stand, one drawer and required furniture and beddings and sufficient lighting and closet space. The two clients bathrooms are clean, sanitary and in a good working condition. The hot water temperature in two bathrooms were tested 105 degrees F which is within the Title 22 regulation. All the appliances in the kitchen and living room are working properly. The knives and all the sharp utensils are stored and locked in the lock box in the kitchen drawer. All the cleaning supplies and chemicals are stored and locked in the cabinet in the garage. The hallway light is always on during night time while client need to access the non-private bathroom. LPA inspected the carbon monoxide detectors is working properly. The facility also has a pool in the backyard and its locked with a five feet high fence. The passageway, walkway and the patio are free of obstruction. The facility also has a telephone service on the premises. The facility also has additional personal hygiene products for client and its stored in the hallway cabinet. The extra linen and towels also stored in the hallway cabinet.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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 3
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: 12/19/2023
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3. Operational Requirement: Currently there's no client in the facility. The facility would follow the fire clearance approval for ambulatory status. The facility would also allow client to participate in community activities. The facility also has a shaded area with table and chairs for client to utilize the outdoor activity.

4. Staffing: Currently there's no client reside in the facility, therefore no staff is currently working at the facility.

5. Personnel Records/Training: Currently there's no staff working at the facility, therefore no staff file to be reviewed.

6. Client's Right: Currently there's no client reside in the facility and therefore there's no client with postural support. Also the facility would provide internet service with at least one internet access device for client to communicate with the day program or family.

7. Food Service: The facility has a ample supply with 2 days perishable and 7 days non perishable food supply in the facility. All the food are stored properly in the facility. The refrigerator temperature is within the required temperature.

8. Client Records/Incident Report: Currently there's no client in the facility and therefore there's no client file to review.

9. Health Related Services: Currently there's no client reside in the facility and no client's medication to be reviewed. All medication in the facility are centrally stored.

10. Incidental Medical Services: Currently there's no client reside in the facility, therefore there's no client is on any restricted health condition plan and no client has any prohibited health condition.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 12/19/2023
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11. Disaster Plan : The facility has an updated Emergency Disaster plan dated on 6/15/2023 and the facility has two appropriate alternative shelter location.

12. Emergency Intervention: It's not applicable for the facility at the present time.

No deficiencies were observed during the annual inspection.

Exit Interview conducted and a copy of the report was provided to administrator Eileen Singh.

(Due to there's no client currently reside in the facility, therefore there's no staff and client interview during the inspection)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3