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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507208788
Report Date: 06/02/2023
Date Signed: 06/02/2023 12:07:18 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/02/2023 12:07 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:ROWENA'S HOME CARE 2FACILITY NUMBER:
507208788
ADMINISTRATOR:PABLO, ROWENA MFACILITY TYPE:
740
ADDRESS:6107 TERMINAL AVENUETELEPHONE:
(808) 429-0253
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY:6CENSUS: 5DATE:
06/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Rowena Pablo AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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On 6/2/2023 at 9:45am, Licensing Program Analysts (LPAs) Jennifer Fain and Maja Jensen arrived at this facility unannounced to conduct an annual inspection visit. LPAs met with the Administrator Rowena Pablo and explained the purpose of the visit.

LPAs Fain and Jensen inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is an RCFE facility with a current census of 5. Facility has a hospice waiver for 4 and today has 3 residents on hospice. Facility has 5 bedrooms and 2 bathrooms for resident use. Facility has a dining area off of the kitchen and a formal living room. Facility currently provides care for 0 ambulatory residents, 5 non ambulatory residents, none of which are bedridden.

Water temperature reads 112.3 which is within the regulated temperature of 105*F to 120*F in the bathroom and room temperature reads 73 degrees Fahrenheit. LPAs observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were sanitary and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers were serviced 1/31/2023 and are in compliance. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and accessible to staff.

Continued on 809C
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ROWENA'S HOME CARE 2
FACILITY NUMBER: 507208788
VISIT DATE: 06/02/2023
NARRATIVE
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During this inspection 5 of 5 resident files and 3 of 3 staffing files were reviewed for regulatory compliance. All staff files contained required contents including staff training requirements. All staff noted on LIC 500 were verified to have criminal background clearances. Resident files reviewed contained all required contents including but not limited to, medical assessments, and updated appraisal forms as required. 5 of 5 Resident files contained a "no refunds" clause. Facility’s liability insurance is current and up to date per regulatory requirements. Facility does not contain any bodies of water. LPAs observed personal rights, resident council and complaint information posted. Facility has appropriate internet access available for resident use. LPAs reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills. LPA Fain requested and received updated copy of the facility lease agreement and liability insurance.

Deficiencies are being cited from the Health and Safety Code (HSC). Failure to correct deficiencies may result in the assessment of civil penalties.

Exit interview was held and a report and appeal rights were given to Administrator Rowena Pablo.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/02/2023 12:07 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: ROWENA'S HOME CARE 2
FACILITY NUMBER: 507208788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2023
Section Cited
HSC
1569.652(c)

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A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to
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The licensee agrees to immediately cease the no refund policy and will email an attestation stating that the no refund policy has been discontinued. The licensee will email LPA Jensen at Maja.Jensen@dss.ca.gov the updated admission agreements by the plan of correction due date.
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 the resident’s estate, within 15 days after the personal property is removed.
This requirement was not met as evidenced by: based on LPA Jensen's review of resident files. 5 of 5 files contained "no refund upon death" clauses. This poses a potential risk to the health, safety and personal rights of residents in care.
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
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