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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408657
Report Date: 07/22/2022
Date Signed: 07/22/2022 02:57:53 PM


Document Has Been Signed on 07/22/2022 02:57 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: 3DATE:
07/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Max ZapantaTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno arrived at the facility for the purpose of delivering findings on complaint investigation (#56-AS-20220715090758). During LPA complaint investigations, the Department discovered that Resident 1 records were not kept in the facility. Refer to LIC-809D for deficiency cited.

An exit interview was conducted where this report, LIC-809D, and appeal rights were discussed and provided
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
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 2


Document Has Been Signed on 07/22/2022 02:57 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
, CA 92507


FACILITY NAME: RODELLA HOME CARE
FACILITY NUMBER: 366408657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2022
Section Cited

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Resident Records: Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.

This requirement was not met as evidenced by:
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During inspection of records, LPA was informed by Licensee that Resident 1 records were given to the new facility where the resident relocated.
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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2