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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608164
Report Date: 02/10/2023
Date Signed: 02/13/2023 08:56:03 AM

Document Has Been Signed on 02/13/2023 08:56 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 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:
02/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Eadgitha Manlad TIME COMPLETED:
12:15 PM
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LPA Angelica Rea conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Staff, Eadgitha Manalad who assisted with the visit. Ms. Manalad stated that Administrator, Ronalad Manalad is out of the country. Assistant Administrator, Evelyn Schaffer, arrived at the facility a short time later.

LPA Rea discussed infection control practices with Ms. Manalad, toured the facility inside and out, reviewed food supply, staff files, and reviewed resident medications.

Bedrooms have the required furniture including bedframes, dressers, lamps and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The front and backyard are well maintained. The resident bathroom is clean and have the required grab bars in the shower and near the toilets. Showers also have non-skid materials. The hot water temperature measured at 117.2 degrees F. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors & carbon monoxide detector were tested and operational. LPA observed a sufficient supply of PPE. Infection control signs were observed throughout the facility.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview conducted, copy of report provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
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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