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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607689
Report Date: 08/27/2022
Date Signed: 08/30/2022 10:21:19 AM

Document Has Been Signed on 08/30/2022 10:21 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:AMERICARE ASSISTED LIVING OF ROLLING HILLSFACILITY NUMBER:
197607689
ADMINISTRATOR:EDNA DIMALANTAFACILITY TYPE:
740
ADDRESS:4826 ROCKBLUFF DR.TELEPHONE:
(310) 422-5364
CITY:ROLLING HILLS ESTATESTATE: CAZIP CODE:
90274
CAPACITY: 6CENSUS: 3DATE:
08/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Leia Joaquin, AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Antonio Bayco, Care giver and later met Leia Joaquin with administrator and the purpose of today’s visit was explained.

There are currently (3) residents in the facility. (2) residents are ambulatory, (1) are non-ambulatory, (0) bedridden. The facility is a single-story structure located in a residential neighborhood. It consists (7) bedrooms, (2) full bathrooms, The front has a ramp and Bedroom #7 has a ramp outside of French doors, and the French living room doors have a ramp outside also. Kitchen, living room, dining room, shaded back yard, front yard, laundry room in the attached 2 car garage.

LPA and Antonio toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1, 2, & 5 are occupied by residents and contain the mandated furniture. Bedroom 3, 4, & 6 are vacant. Bedroom 7 is a staff bedroom. The (1) bathrooms are clean and operational. 2nd bathroom is a staff bathroom. First aid kit is fully stocked with manual; smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. (1) Resident file along with medications are current. (1) Staff file is current. Ample supply of perishable and nonperishable food, hot water temperature is between 105 - 120 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, (2) fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMERICARE ASSISTED LIVING OF ROLLING HILLS
FACILITY NUMBER: 197607689
VISIT DATE: 08/27/2022
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During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked. Sanitizer/soap, paper towels, in all the bathrooms and additional sanitation supplies are stored in the garage. LPA observed staff wearing masks, resident private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, Fit testing completed for staff, and required postings throughout the facility. Visitor designated area, facility has internet & Computers for residents to use, resident’s temperatures are checked and logged (once a day). Emergency contacts updated and posted; PPE's are enough for 30 days.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

No Technical Advisory (TA) issued

An exit interview conducted with Leia Josquin, Administrator and a hard copy of report provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2022
LIC809 (FAS) - (06/04)
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