<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608164
Report Date: 07/29/2021
Date Signed: 07/29/2021 02:47:13 PM

Document Has Been Signed on 07/29/2021 02:47 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:
07/29/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Eadgitha Jody ManaladTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Nicol Wesley an unannounced Annual Continuation at the facility and met with staff Lydia Teofisto, Briana Schaefer, Proceso Dalina Gayda, 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. A Pre screening area with PPE supplies was observed upon entry into the facility. The mitigation plan was approved on 04/27/2021. During the visit Administrator Ronald Manalad arrived and joined the visit.

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).

During todays visit, LPA attempted to access the Infection control tool, and it was not working. LPA Wesley contacted LPM Yee for assistance with the inspection tool domain, as well as contacted FAS specialist Paul Zoch who was not available at the time of visit. The facility has postings at the front entrance, bathrooms, and throughout the facility. Thermometer, visitation/sign in book, hand sanitizing gel and masks were located at the entry and throughout the facility. The facility was reminded to review and comply with PIN 21-28 ASC, in which effective 08/09/21 PIN 21-32-ASC will supersede PIN 21-28 ASC. LPA conducted a complete tour of the facility, and observe the supply of food, resident medications/medication logs were in compliance. The fire alarm system is hardwired, smoke detectors/carbon monoxide detector were tested and are operable. LPA observed one fire extinguisher in the kitchen area. The water temperature was tested and measured 108.6 degrees F. Administrators certificate for Evelina M Schaefer RCFE #6006565740 expires 11/10/2021 and Ronald R Manalad RCFE expires 09/10/2021.

The following deficiency is being cited in accordance with California Code of Regulations, Title 22, Division (6) and Chapter (8) on the LIC 809D. a copy of this report, along with proof of corrections form(LIC 9098), and appeal rights were given during the exit interview.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2021
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
Document Has Been Signed on 07/29/2021 02:47 PM - It Cannot Be Edited


Created By: Nicol Wesley On 07/29/2021 at 01:15 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ROLYN HOME
FACILITY NUMBER: 197608164

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/28/2021
Section Cited
CCR
87303(a)

1
2
3
4
5
6
7
Maintenance and Operation
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 was not met as
evidenced by: During the visit, LPA
1
2
3
4
5
6
7
The Administrator will make sure all items are removed from the covered patio, and this will also allow the passage way from being congested. Send proof of correction(LIC 9098) to LPA Wesley by POC date 08/28/21.
8
9
10
11
12
13
14
observed the interior walls are scratched from use of wheelchairs/equipment and are in need of painting. Medical equipment, potty chair, wheel chairs, hoyer lifts need to be removed from the covered patio that prohibits the passage way from being cleared. which poses a potential health risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Rebecca Orendain
LICENSING EVALUATOR NAME:Nicol Wesley
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2