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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608164
Report Date: 07/27/2021
Date Signed: 07/27/2021 04:38:38 PM

Document Has Been Signed on 07/27/2021 04:38 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ROLYN HOMEFACILITY NUMBER:
197608164
ADMINISTRATOR:RONALD MANALADFACILITY TYPE:
740
ADDRESS:10622 LEEDS STREETTELEPHONE:
(562) 868-1560
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 6CENSUS: 4DATE:
07/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Eadgitha ManaladTIME COMPLETED:
04:45 PM
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Licensing Program Analysts (LPAs) Nicol Wesley an unannounced Required 1 year inspection at the facility and met with staff Lydia Teofisto, Briana Schaefer, and Eadgitha(Jody) Manalad and explained the purpose for todays visit. Prior to the visit LPA Wesley conducted a risk assessment for on-site inspections. The facility phone number is 562 868 1560.

The facility consist of four resident bedrooms(1 for staff), two bathrooms(1 for staff), living room, dining room, kitchen, den, back yard with covered patio and an unattached garage(storage and overflow of food).

Due to time constraints, LPA Wesley will return and complete the inspection on another day.

Administrators certificate for Evelina M Schaefer RCFE #6006565740 expires 11/10/2021 and Ronald R Manalad RCFE expires 09/10/2021.

There were no deficiencies cited.

Exit interview conducted.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2021
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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