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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001093
Report Date: 10/23/2023
Date Signed: 10/23/2023 11:43:22 AM


Document Has Been Signed on 10/23/2023 11:43 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
ORANGE COUNTY RO, 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:
10/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Foster RingorTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by Foster Ringor, Administrator and LPA explained the nature of the visit.

There are 12 residents at the facility and there are no residents receiving hospice services currently. LPA accompanied by the Administrator began the tour of the inside and outside of the facility. LPA observed residents throughout the facility in common areas and in their bedrooms. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in the refrigerator/freezer located in garage. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in dining room. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPA inspected the bathroom and LPA measured the hot water temperature which measured 114.2 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked underneath kitchen sink and locked storage cabinet in laundry unit. The facility has an available clean supply of linens. LPA inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors were tested and found to be operational. LPA observed facility has a sprinkler system as well, which is serviced by the fire authority. LPA observed fire extinguishers throughout the facility with service date of June 07, 2023. Fire drills are conducted twice a year. LPA toured the outside of the facility and

Continued on LIC809-C
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
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)
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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ROCHELLE MANOR
FACILITY NUMBER: 306001093
VISIT DATE: 10/23/2023
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observed outdoor passageways are free of obstructions. LPA observed there are shaded seating areas for residents’ enjoyment. LPA began review of records. LPA reviewed three resident records. All the required documentation was present and current in the residents’ files reviewed. LPA reviewed three employee records. All employees present have a criminal record clearance and are associated to the facility.

Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the Administrator and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
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
LIC809 (FAS) - (06/04)
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