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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880541
Report Date: 05/10/2022
Date Signed: 05/10/2022 12:16:30 PM


Document Has Been Signed on 05/10/2022 12:16 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: 4DATE:
05/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Gertrude "Trudy" Okoro - Licensee/AdministratorTIME COMPLETED:
12:45 PM
NARRATIVE
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On this date, Licensing Program Analyst (LPA) Crystal Colvin made an unannounced visit to the facility to investigate a complaint #18-AS-20220503084418. During today's inspection, LPA Colvin observed the following deficiencies:
  • Accessible Chemicals: LPA Colvin observed the door for the laundry room and the garage to be propped open with a bottle of bleach. LPA Colvin observed other chemicals on the ground between the washing machine and dryer. Deficiency cited.

  • Living Accommodations: During LPA Colvin's inspection of the facility. LPA Colvin observed that one of the resident bedrooms (the only single bed resident room) to not have a door. Instead, LPA Colvin observed a curtain hung up across the doorway to provide some element of privacy to the resident (R1). When LPA Colvin inquired about the missing door, Licensee/Administrator Gertrude "Trudy" Okoro stated that it was removed in order to be able to use a Hoyer Lift for the resident. Deficiency cited.

  • Alterations to Building: During today's inspection, LPA Colvin observed a hidden office/bedroom adjoining the facility dining room. In this room, LPA Colvin observed a bed, which the Licensee/Administrator stated was used sometimes by her and sometimes by her husband. LPA Colvin inquired about when the changes were made to add this room, but the Licensee/Administrator was unsure. LPA Colvin requested a copy of the facility's building sketch, which was provided. LPA Colvin pointed out to the Licensee/Administrator that this room was not noted on the sketch, and therefore, must have come after the facility was licensed. There is also no note of the room in the Pre-Licensing inspection done on 11/28/18. Community Care Licensing (CCL) was not notified of the change and updated facility sketch was not provided to CCL to update the facility's file. Deficiency cited. LPA Colvin additionally inquired about if the facility obtained a building permit for the room .
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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 4


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: 05/10/2022
NARRATIVE
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Licensee/Administrator was unsure if a building permit was obtained, and could not provide LPA Colvin with a copy of any permit. Deficiency cited.

Due to observations made by LPA Colvin, the facility was cited and deficiencies are noted on the LIC809D page(s). LPA Colvin conducted an exit interview with Administrator/Licensee Gertrude "Trudy" Okoro, and a copy of this report, LIC809Ds, and appeal rights was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/10/2022 12:16 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: 05/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2022
Section Cited
CCR
87309(a)

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Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by:
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Licensee agrees to remove chemicals from accessiblity of residents. Licensee to tour facility and ensure all potentially hazardous chemicals are locked. Licensee may self-certifiy to LPA Colvin once complete.
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Based on observations, the Licensee did not comply with the above requirement with at least one area of the facility. LPA Colvin observed a bottle of bleach to be propping open the doors for the laundry room and garage. This is an imemdaite safety risk to residents in care.
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Deficiency Dismissed
Type A
05/11/2022
Section Cited
CCR87307(a)(2)(a)

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Personal...Services: (a)...shall be large enough to provide...privacy for the residents...(2) Resident bedrooms shall...at a minimum,...(A) ...be large enough to allow for easy passage between and comfortable usage of...other required items... and any resident assistant devices... This was not met by:
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Licensee agrees to do one of the following: Move R1 to a larger room which will accomodate their medical equipment, OR replace the door on R1's room (can be another style of door which is less obstructive to equipment). Licensee to provide plan and proof of correction to LPA Colvin.
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Based on interviews and observations, the licensee did not comply with the above regulation with one resident. LPA Colvin observed that R1's bedroom is missing a door and only a curtain is hung to provide some privacy. Licensee states this is due to Hoyer Lift. This is an immedaite personal rights violation of R1.
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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: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 05/10/2022 12:16 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: 05/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2022
Section Cited
CCR
87305(a)

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Alterations to Existing Building or New Facilities: (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidenced by:
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Licensee agrees to contact the City Planning Department to ensure the addition is on file and approved. Licensee to also contact County Code Enforecment to have the addition inspected for compliance. Licensee to provide LPA Colvin with approval from City and County agencies for the addition.
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Based on interviews and lack of records, the Licensee did not comply with the above regulation with one room of the facility. LPA Colvin observed an addition to the facility (office/bedroom). Licensee states they do not have proof of building permit. This is a potential safety hazard to staff and residents.
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Type B
05/24/2022
Section Cited
CCR87208(a)

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Plan of Operation: (a) Each facility shall have and maintain a current, written definitive plan of operation...Any significant changes...shall be submitted to the licensing agency for approval... This requirement was not met by:
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Licensee agrees to submit udpated Facility Sketch to LPA Colvin, which includes all buildings/rooms and their stated purpose. Plan of Correction due date is 5/24/22.
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Based on observation and record review, the Licensee did not comply with the above regulation with one aspect of the Plan of Operation. LPA Colvin observed that the facility sketch did not include the added office/bedroom. This is a potential safety hazard to residents and staff.
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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: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4