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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412134
Report Date: 07/28/2021
Date Signed: 07/28/2021 10:21:53 AM

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:ROSALINA'S HOME CAREFACILITY NUMBER:
336412134
ADMINISTRATOR:OLAH, ROSALINAFACILITY TYPE:
740
ADDRESS:6890 JURUPA ROADTELEPHONE:
(951) 360-1334
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:6CENSUS: DATE:
07/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rosalina Olah - LicenseeTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Crystal Colvin arrived to the facility unannounced for the purpose of following up on the passing of a resident (R1). LPA Colvin met with Licensee Rosalina Olah and informed her of the purpose of today's visit.

During today's visit, LPA Colvin interviewed the Licensee regarding the events that lead up to R1's passing, reviewed R1's file including Power of Attorney Paperwork, and interviewed Administrator Marcus Olah via telephone. During review of R1's file, LPA Colvin observed a completed Death Report for R1, which was never received by Community Care Licensing (CCL). LPA Colvin inquired about if the Death Report was ever submitted, and both the Licensee and Administrator stated that they faxed it in. LPA Colvin followed up on what fax number they sent it to, and observed that there was a mistake and the facility faxed the report to CCL's phone number, and not the fax number. LPA Colvin pointed this mistake out to Licensee Rosalina and additionally provided her with CCL's correct fax number.

An exit interview was conducted with Licensee Rosalina Olah where a copy of this report was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
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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