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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001093
Report Date: 05/17/2022
Date Signed: 05/17/2022 12:25:51 PM

Document Has Been Signed on 05/17/2022 12:25 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ROCHELLE MANORFACILITY NUMBER:
306001093
ADMINISTRATOR:ALFREDO RINGORFACILITY TYPE:
740
ADDRESS:12841 ADELLE STTELEPHONE:
(714) 537-3188
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 20CENSUS: 12DATE:
05/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Foster Ringor TIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Marin made an unannounced case management visit to this facility. LPA met with Administrator (Ad) Foster Ringor and stated the purpose of this visit.

On March 14, 2022, LPA Marin conducted an unannounced case management visit for an incident that occurred in the facility last March 4, 2022. Based on observation, file review and interview, the following are the findings: On March 9, 2022, Facility received a verbal report from Staff 1 alleging Staff 2 did a personal rights violation on Resident 1. Facility investigated the incident and determined to end the employment of Staff 2 for not following the facility procedure. Per interviews, facility did a visual check on Resident 1(R1) and did not notice any concerns related to the incident. Facility informed the responsible party about the alleged incident. Facility made effort to bring resident for a medical evaluation. File review of facility document indicated that the annual staff training log for 2021-2022 lacked training on Resident's Personal Rights.

Deficiency was observed; and citation was issued per Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview with AD F. Ringor. LPA discussed the deficiency, citation, and appeal rights. LPA left copies of this report, deficiency page, and appeal rights in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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 05/17/2022 12:25 PM - It Cannot Be Edited


Created By: Albert Marin On 05/17/2022 at 09:17 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROCHELLE MANOR
FACILITY NUMBER: 306001093

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2022
Section Cited
CCR
87411(c)(3)(C)

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87411 Personnel Requirements - General. All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training...Residents rights, as specified in Section 87468, Personal Rights. This requirement was not met as evidenced by:
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AD will ensure that the staff will receive the training on personal rights. Proof of correction will be provided to CCLD on or before May 31, 2022.

Copy of the reguation cited was left in the facility for full reference.
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Based file review and interview, facilty miss to provide training facility staff regarding Personal Rights. Facility failed to document annual training for Staff 1 and Staff 2 regarding resident's personal rights. This poses potential personal rights violation against residents 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:Luz Adams
LICENSING EVALUATOR NAME:Albert Marin
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022


LIC809 (FAS) - (06/04)
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