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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005668
Report Date: 12/13/2022
Date Signed: 12/13/2022 11:34:54 AM


Document Has Been Signed on 12/13/2022 11:34 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:ROLLING HILLS GUEST HOMEFACILITY NUMBER:
306005668
ADMINISTRATOR:MIRABUENO, MARIA PRICILLAFACILITY TYPE:
740
ADDRESS:1000 ROLLING HILLS DRIVETELEPHONE:
(213) 446-1695
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:6CENSUS: 5DATE:
12/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Ricardo TiopengcoTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Jessica Cho arrived at Rolling Hills Guest Home to conduct an unannounced Required 1 Year Inspection with an emphasis on Infection Control. At 10:25am, LPA Cho was greeted and granted entry by Caregiver Haitham Gomaa followed by Ricardo Tiopengco. At 10:30am, Caregiver Tiopengco contacted Administrator Maria Mirabueno who then consented Caregiver Tiopengco to assist with the tour and sign the report. LPA completed the Coronavirus 2019 (COVID-19) screening procedure upon entry. There are no active COVID-19 cases as of today. LPA observed a thermometer at the check-in station and the required COVID-19 precautionary signs posted on the entrance door and throughout the facility. At 10:39am, LPA began the tour with Caregiver Tiopengco. There are a total of four resident bedrooms and two resident bathrooms. There is one private staff bedroom. LPA checked the resident bedrooms. The resident bedrooms had the required furnishings. The resident bathrooms were checked. The toilets worked properly, showers were free of mold/mildew, grab bars were secure, slip mats were in place, and bathrooms were adequately stocked with hand soaps and paper towels. Hand washing signs were observed in the bathrooms. The hot water temperature in the resident bathrooms measured at 121.1 degrees Fahrenheit in Bathroom #1 and 122.3 degrees Fahrenheit in Bathroom #2. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was mounted, fully charged, and serviced on 05/05/2022. Smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. LPA Cho toured the outside grounds. There was shading and sufficient seating for residents. The exit gate was self-closing and self-latching. LPA observed sufficient supply of emergency food/water and PPEs.

Based on the observations made during today's visit, no deficiency is being cited as per Title 22 Division 6 Chapter 2 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit. An exit interview was conducted with Caregiver Ricardo Tiopengco, and a copy of this report was provided during this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
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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