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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006133
Report Date: 10/02/2023
Date Signed: 10/02/2023 11:42:26 AM

Document Has Been Signed on 10/02/2023 11:42 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:HILLS OF ROCKAWAY, THEFACILITY NUMBER:
306006133
ADMINISTRATOR:MEDINA, ALLENFACILITY TYPE:
740
ADDRESS:919 E ROCKAWAY DRIVETELEPHONE:
(909) 450-1699
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 6DATE:
10/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Allan Medina and Jeff BencitoTIME COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced health and safety visit in conjunction with complaint #22-AS-20230927113557. LPA was greeted and granted entry into the facility and explained the reason for the visit.

During the course of the complaint investigation, LPA toured the facility. LPA observed a clean and sanitary facility with ample food supply. At 10:40 AM, LPA observed pre-poured unsecured medications sitting on a counter in the kitchen as well as an unlocked cupboard containing medications. LPA observed residents relaxing or sleeping in the facility. All residents appeared clean and well taken care of. Residents verbalized satisfaction with facility services. LPA observed a clean and shaded outside area. Appliances are operational.







Based on the observations made from today's visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided as well as Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2023
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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Document Has Been Signed on 10/02/2023 11:42 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 10/02/2023 at 11:06 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: HILLS OF ROCKAWAY, THE
FACILITY NUMBER: 306006133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2023
Section Cited
CCR
87465(h)(2)

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Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not being met as evidenced by:
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Staff secured medications during visit.
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Based on observation, Licensee failed to ensure centrally stored medications are inaccessible to residents in care. This poses an immediate health and safety risk to 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023


LIC809 (FAS) - (06/04)
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