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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880541
Report Date: 08/11/2022
Date Signed: 08/11/2022 12:20:07 PM


Document Has Been Signed on 08/11/2022 12:20 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:
08/11/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:ADMINISTRATOR GERTRUDE OKOROTIME COMPLETED:
12:20 PM
NARRATIVE
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On August 11, 2022, Licensing Program Manager (LPM) Jazmond Harris and Licensing Program Analyst (LPA), Venus Mixson met with Administrator, Gertrude Okoro at the Community Care Licensing Division (CCLD) Office located at 1650 Spruce Street, Suite # 200 in Riverside, CA. 92507. LPM and LPA explained the purpose of the meeting.

The following was discussed in the meeting:

The Riverside Regional Office received a Serious Incident Report (SIR) dated June 29, 2022 regarding a head injury to Resident #1. It was advised that Resident #1 fell and sustained a bruise, bump, and cut to the back of Resident #1's head. Facility staff contacted hospice care to advise of the incident, but did not contact emergency services for further evaluation. It was also reported that on July 21, 2022, Resident #2 fell and had bruising notated on the left orbital area. Facility staff did not indicate on the serious incident report that emergency medical services were contacted. Administrator denied medical services were contacted for the incident, due to no apparent imminent health concerns. LPM explained the importance of contacting emergency services for all head injuries. According to CCLD Regulations, 87465 (a)(1), Incidental Medical and Dental Care. This poses an immediate health and safety or personal rights risk to residents in care. Deficiencies will be cited.

The Riverside Regional Office received a SIR regarding Resident #2 pertaining to an incident which occurred on July 14, 2022. It was reported
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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 3


Document Has Been Signed on 08/11/2022 12:20 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: 08/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2022
Section Cited

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87465 (a)(1). Incidental Medical and Dental Care.
The licensee shall arrange, for medical care appropriate to the conditions and needs of residents.
This requirement is not met as evidenced by:
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Based on record review and interviews, the Administrator did not contact emergency medical services for Resident #1 on 6/29/2022 and Resident #2 on July 21, 2022, regarding head injuries.
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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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: 08/11/2022
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that Resident #2 had a behavioral incident. Due to the behavioral incident, Administrator has increased supervision of the resident. No further concerns at this time.

An exit interview was conducted, a copy of the report, along with the LIC 9099-d, 811, and appeal rights were provided.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC809 (FAS) - (06/04)
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