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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607689
Report Date: 05/08/2025
Date Signed: 05/08/2025 04:10:45 PM

Document Has Been Signed on 05/08/2025 04:10 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:AMERICARE ASSISTED LIVING OF ROLLING HILLSFACILITY NUMBER:
197607689
ADMINISTRATOR/
DIRECTOR:		EDNA DIMALANTAFACILITY TYPE:
740
ADDRESS:4826 ROCKBLUFF DR.TELEPHONE:
3104225364
CITY:ROLLING HILLS ESTATESTATE: CAZIP CODE:
90274
CAPACITY: 6CENSUS: 4DATE:
05/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Leia Joaquin, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:16 PM
NARRATIVE
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On 04/08/25, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with staff one, Leia Joaquin Administrator (S1). LPA explained the purpose of today’s visit. The facility is licensed to serve (6) residents ages 60 and above. Of which (4) may be non-ambulatory and (2) bedridden. Approved hospice waiver for (1). Currently the facility has four (4) residents in care.
The facility is a single-story structure located in a residential neighborhood. Disability ramps are located at the front door and back door for the ease of relocation of residents considered "non-ambulatory". It consists of (7) bedrooms, (2) full bathrooms, shaded back yard, front yard and an attached 2 car garage which contains a clothes washer and dryer.
LPA toured the physical plant with staff. There were no bodies of water or obstructions on the premises. A total of seven (7) rooms and two (2) bathrooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided in each room and storage for the residents’ personal belongings was observed, larger than 8 cubic feet. Bathrooms were observed and no mold or mildew was observed and were within title 22 regulations. LPA inspected the smoke/carbon monoxide detectors and all were in operable condition. The water temperature measured between 105F° and 120F°, which indicates the water utility is within title 22 regulations. LPA observed the interior of the facility to be generally clean, sanitary, and appropriately furnished at the time of the visit. LPA observed Room #3 has cobwebs, living room has cobwebs (above room #1), this deficiency was corrected on site, please see LIC9102-TA. While LPA conducted an outside tour of facility, LPA observed two (2) wasp nests in the backyard One (1) nest is above the window to room two (#2), another nest is above the window to room three (#3). Please see LIC809-D. Storage areas for personal hygiene were observed. Sharp objects were locked and inaccessible to residents in care. Evaluation Report Continues, see LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: AMERICARE ASSISTED LIVING OF ROLLING HILLS
FACILITY NUMBER: 197607689
VISIT DATE: 05/08/2025
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A review of (3) residents' service files, (3) staff personnel files were checked. (3) Medication Administration Records (MAR) were reviewed. LPA observed resident four (R4) are missing Physician/Mental/Dentist emergency contact, please see LIC809-D.

Two (2) deficiencies have been cited, please see LIC809-D.

Two (2) Technical assistance notes have been provided, see LIC9102-AN.

An exit interview was held with Leia Joaquin, Administrator (S1) and a copy of this report, appeal rights and deficiencies have been provided.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Mario Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/08/2025 04:10 PM - It Cannot Be Edited


Created By: Mario Leon On 05/08/2025 at 03:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AMERICARE ASSISTED LIVING OF ROLLING HILLS
FACILITY NUMBER: 197607689

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(f)(1)
Incidental Medical and Dental Care Services
(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation of record review, the licensee did not comply with the section cited above in two out of three (R3,R4) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2025
Plan of Correction
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Licensee (S1) has agreed to contact responsible parties (R4) to request a choice of personally preferred physician/mental/dentist, on or prior to the POC due date. S1 will forward, via email at Mario.Leon@DSS.CA.GOV, updated contact Idenitification of LIC601, ID & emergency contact. S1 was provided an appropriate dentist for R3 while LPA was on-site. S1 was provided an appropriate physician/mental/dentist for R4 whiole LPA was on site.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in allowing two (2) wasp nests to remain in good health, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2025
Plan of Correction
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Nests were removed by professional exterminators while LPA was on-site.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Mario Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2025


LIC809 (FAS) - (06/04)
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