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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001093
Report Date: 03/14/2022
Date Signed: 03/14/2022 11:50:16 AM

Document Has Been Signed on 03/14/2022 11:50 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
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: 11DATE:
03/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Administrator Foster Ringor TIME COMPLETED:
12:15 PM
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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 10, 2022, Community Care Licensing Division (CCLD) Orange Office received an incident report from the facility. The incident stated an allegation on personal rights violation of a resident in the facility.

With assistance from AD Ringor, LPA Marin toured the interior and exterior portions of the facility. LPA observed resident's rooms and common areas. LPA conducted random interviews and file review. LPA discussed with AD the requested documents. AD agreed to provide the documents to CCLD on or before 5:00 PM of March 22, 2022.

For this visit, no citation was issued.

LPA Marin conducted an exit interview with AD F. Ringor. Due to technical issue, LPA Marin will send copy of this report to the email address of the facility on file. AD agreed to acknowledge the receipt of this report and the list of documents request.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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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