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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880541
Report Date: 12/20/2021
Date Signed: 12/20/2021 05:16:56 PM


Document Has Been Signed on 12/20/2021 05:16 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: 3DATE:
12/20/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Caregiver Traci BrownTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Javina George arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20211214124454.

At the time of LPA visit a series of several beeps or chirping, were heard throughout LPAs visit. The beeping or chirping was coming from multiple smoke detectors throughout the facility located inside of resident and staff bedrooms, hallway and common areas.

Due to the non-operable smoke detectors a deficiency is being cited, and immediate civil penalties of $500 are being assessed according to the California Code of Regulations.

An exit interview was conducted and a copy of this report, appeal rights LIC421IM was provided to Caregiver Traci Brown.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2021
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 12/20/2021 05:16 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: 12/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type A
12/21/2021
Section Cited

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Civil penalties;..:(c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation...citation for any of the following serious violations:2) (A) Fire clearance violations, including, but not limited to...inoperable smoke alarms, and inoperable fire alarm systems.
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Licensee agrees to replace all smoke detectors in facility by 5pm on the due date indicated.
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This requirement was not met as evidenced by:
Based on observation, the Licensee did not comply with the above regulation in at least 3. LPA George obeserved non-operational smoke detectors in various locations: Bedrooms, hallways and common area. This is an immediate safety risk to residents.
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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 EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2021
LIC809 (FAS) - (06/04)
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