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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408657
Report Date: 07/01/2022
Date Signed: 07/01/2022 02:59:46 PM


Document Has Been Signed on 07/01/2022 02:59 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
, CA 92507



FACILITY NAME:RODELLA HOME CAREFACILITY NUMBER:
366408657
ADMINISTRATOR:AGPALO, NORMA AREVALOFACILITY TYPE:
740
ADDRESS:17446 MADRONE STTELEPHONE:
(909) 574-6832
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY:6CENSUS: 4DATE:
07/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Norma Agpalo - AdministratorTIME COMPLETED:
03:02 PM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA met with administrator Norma Agpalo, who confirmed that there are currently no cases/exposures of COVID-19 within the facility.

During the inspection, LPA Bueno interviewed Administrator regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA observed appropriate postings in the facility, including COVID-19 symptoms and infection control postings, which were in accordance with the Department's guidelines. LPA observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person and mitigation plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for residents with COVID-19 positive results and/or exposures.

LPA Bueno and administrator Agpalo toured the facility inside and out. LPA observed that the facility appears to be meeting operational requirements. LPA observed that all utilities and appliances were functioning properly and all passageways clear of obstruction. The facility was equipped with sufficient food supplies. All areas of the facility, including resident bedroom and bathrooms, appeared to have appropriate furnishings, are clean, and in good repair. LPA observed no apparent health and safety risks at the time of visit. A technical advisory was provided to remind staff to wear properly fitted face coverings.

Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview was conducted where this report and LIC9102 were discussed and copies were provided to Licensee at the conclusion of the inspection.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022
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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