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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880541
Report Date: 06/09/2023
Date Signed: 06/09/2023 02:28:33 PM

Document Has Been Signed on 06/09/2023 02:28 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: 4DATE:
06/09/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Leocardia Ogolla, CaregiverTIME COMPLETED:
02:45 PM
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 Licensing Program Analyst (LPA) Javina George made an unannounced Plan of Care (POC) visit to confirm the whereabouts of Resident #1 (R1), as they were to return to the facility as apart of the plan of correction for complaint control # 18-AS-20230602124116. LPA was greeted and granted entry by Leocardia Ogolla, Caregiver. The administrator was available via telephone as they had a personal appointment, during the time of LPAs visit and was not able to come to the facility. LPA conducted a tour of the interior and the exterior of the facility, and observed the following deficiencies:

LPA observed for Resident #1(R1) to not be at the facility and was informed that R1 was no longer at the facility. Department staff verified that R1 was at the hospital and that they are still ready to be discharged. The hospital staff reported that the Licensee Ms. Okoro is not engaging in attempts to discharge R1 back to the facility, as she is not accepting or returning their phone calls. Ms. Okoro confirmed that she has not picked up R1 from the hospital and claims that the window had not been repaired and that R1's bed was picked up by the insurance company, preventing from having R1 to return to the facility. Due to the POC not being corrected, the following deficiencies were not corrected by the POC due date of 6/7/23, nor at the time of LPAs visit. Civil Penalties are being assessed and will continue to accrue until correction has been submitted: Deficiency is being cited under Title 22 Regulation 87468.2. The POC was to accept R1 back at the facility by 6/7/23. In addition the Licensee was to work with the hospital to ensure that R1 was returned to the facility. Civil penalties are being assessed for the dates of 06/07/2023 to 06/09/2023 in the amount of $100 per day covering the notes days, for a total of $200.00. Civil penalties will continue to accrue at the rate of $100 a day until proof of POC, is submitted.

-Department staff conducted an interview with the Ms. Okoro in regards to R1 returning to the facility. Per Ms. Okoro the POC was met as R1 was admitted to another facility, as she was contacted by another facility regarding R1. The department contacted the other facility and learned that R1 was not admitted and had not reported that they were admitting R1 to the facility. Department staff verified that R1 was still at the hospital.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2023
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ROLLING GREEN SENIOR CARE
FACILITY NUMBER: 331880541
VISIT DATE: 06/09/2023
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As a result the department was provided with false and misleading statements by the licensee Ms. Okoro, and is therefore being cited for false claims.

-During the tour of the physical plant LPA observed for a double pane window in the master bedroom to be broken withe several sharp, and jagged pieces to be sticking out for both residents and staff to be cut and or injured. The window was reported to have been broken on 5/31/23. Ms. Okoro placed Resident #2 (R2) inside the room. R2 is able to ambulate with a walker, the broken window poses an immediate heath and safety concern. Deficiency cited.

-LPA observed for all three (3) resident bedrooms to have camera's located in each corner above the bedroom doors. LPA explained that any form of video surveillance needs to be approved, and to have cameras in the resident bedrooms was a violation of their personal rights as well as privacy. In addition the use of cameras is not included in the facility's plan of operation. LPA did not observe any signed consents from the residents or their responsible parties consenting to the use of video surveillance. Per the Licensee, Ms. Okoro the cameras are used as a safety measure to keep an eye on the residents as they are a fall risk. Deficiency cited.

Based on today's visit, deficiencies were observed in the areas evaluated and cited according to California Code of Regulations, Title 22, Division 6 and listed on the 809D.

An exit interview was conducted, and a copy of this report, 809D, and appeal rights were provided to Leocardia Ogolla, Caregiver.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/09/2023 02:28 PM - It Cannot Be Edited


Created By: Javina George On 06/09/2023 at 12:12 PM
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
, 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: 06/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
06/23/2023
Section Cited

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87207 False Claims
No licencee, officer or employee nof a licensee shall make or dissemenate any false or misleading statement regarding the facility or any of the serives provided by the facility. This requirement is not met as evidenced by:
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1 out of times the licensee stated that R1 was moving to another facility, and denied the hospital's phone calls, were to assist with a plan R1 back to the facility. This poses a potential heath, safety, and personal rights risk to persons in care.
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Proof is to be submitted to the department by 5pm on the due date indicated.
Type B
06/23/2023
Section Cited

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition.. residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy..
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/09/2023 02:28 PM - It Cannot Be Edited


Created By: Javina George On 06/09/2023 at 01:48 PM
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
, 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: 06/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2023
Section Cited

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Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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Based on observations, the Licensee did not ensure that 1 out of 1 time, the facility was in good repair, as the window was broken in the master bedroom on 5/31/23, leaving jagged and sharp edges exposed, to cut or injur anyone that comes in contact. This is an immediate health 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:Joel Esquivel
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023


LIC809 (FAS) - (06/04)
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