<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880541
Report Date: 08/01/2022
Date Signed: 08/01/2022 04:35:00 PM


Document Has Been Signed on 08/01/2022 04:35 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ROLLING GREEN SENIOR CAREFACILITY NUMBER:
331880541
ADMINISTRATOR:OKORO, GERTRUDEFACILITY TYPE:
740
ADDRESS:42007 THOROUGHBRED LNTELEPHONE:
(951) 397-3369
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:6CENSUS: 5DATE:
08/01/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:ADMINISTRATOR GERTRUDE OKOROTIME COMPLETED:
04:33 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On August 1 2022, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced to conduct a case management visit to address concerns regarding the facility reporting to Community Care Licensing (CCL) in a timely manner. LPA was greeted and granted entry by Administrator, Gertrude Okoro, introduced self, and explained the purpose of the visit. LPA met with Administrator and toured the facility for the purpose of conducting a Health & Safety inspection. No deficiencies were observed. LPA Mixson reviewed residents' files and pertinent documents were obtained.

During this visit, LPA Mixson interviewed one staff. No residents were available for interviews. Staff interview revealed that on June 29, 2022, hospice staff was called for Resident #2 (R2). Hospice staff arrived and conducted an evaluation of R2. Pertinent documentation regarding the evaluation was obtained.
Facility staff provided first aid. Facility staff did not report the incident to CCL until July 27, 2022.

On July 27, 2022, the Regional Office was advised of an incident that occurred on July 14, 2022 regarding R4. The Murrieta Police Department and the Community Behavioral Health Assessment Team (CBAT), was called to the facility regarding R4's concerning behaviors. However, the facility did not report to CCL until July 27, 2022 which is a violation of Title 22 regulations. Deficiencies will be cited.

An exit interview was conducted, and this report, along with the LIC 9099-D, LIC 811, and appeal rights were provided to Administrator.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/01/2022 04:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ROLLING GREEN SENIOR CARE
FACILITY NUMBER: 331880541

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/08/2022
Section Cited

1
2
3
4
5
6
7
87211(a)(1)(D)
(a) Each licensee shall furnish a written report within 7 days of the occurrence of any event which threatens the welfare and safety of the resident.
This requirement was not met as evidence by:
The facility failed to report the incident to CCL within seven days.
8
9
10
11
12
13
14
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2