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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507208788
Report Date: 07/11/2024
Date Signed: 07/12/2024 10:01:31 AM


Document Has Been Signed on 07/12/2024 10:01 AM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rowena PabloTIME COMPLETED:
01:30 PM
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Unannounced annual visit made out to this facility on 07/11/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator, Rowena Pablo, who was briefly interviewed at this time.
Current census was 5 residents.
It was learned that there were (3) residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (4) residents under the care of hospice at any given time.
It was learned that this facility has a program to be able to accept and retain dementia residents at any given time. It was learned that there was (1) resident diagnosed with dementia at this time.
It was learned that there was (1) resident receiving services through home health at this time.
Tour of this facility was conducted.
Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Linen closet, located in facility employee office, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time.
Kitchen area was toured.
Kitchen drawers and cabinets were opened and reviewed.
Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times.
Additional food storage units were observed to be present and functional at this time.
Laundry area, located in the facility hallway, was toured.
Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
Medication cabinet, located in the facility kitchen area, was observed to be locked and made inaccessible to the residents at this time. Policies and procedures involving storage, dispensing, and documentation of the
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ROWENA'S HOME CARE 2
FACILITY NUMBER: 507208788
VISIT DATE: 07/11/2024
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resident medications was discussed with the facility designated Administrator at this time.
Administrator certificate, # 6036268740, for Rowena Pablo was observed to have an expiration date of 08/02/2025 and in compliance at this time.
First aid kit, located in the medication cabinet, was reviewed. This LPA observed that it did contain all of the required components at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected by the local fire extinguisher company, Assured Fire Extinguisher, on 01/15/2024 and in compliance at this time.
Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted.
This LPA observed an additional storage unit that was present on the north side of this facility at this time. This storage unit was observed to be locked and made inaccessible to the residents at this time.

A review of (5) facility personnel records was conducted on the LIC 859.
A review of (3) facility resident records was conducted on the LIC 858.

There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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