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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608164
Report Date: 09/15/2023
Date Signed: 09/15/2023 11:14:36 AM

Document Has Been Signed on 09/15/2023 11:14 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:
09/15/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Eadgitha Manalad- DSP/Lead StaffTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of completing the required annual inspection, using the Care Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA met with Direct Support Professional, Eadgitha Manala and explained the purpose for the visit. The facility is licensed to serve (6) elderly adults, ages 60 and over, of which (4) may be non-ambulatory, and (2) may be ambulatory.

Today's visit consisted of:
  • Review of (4) resident's medications and their respective Medication Administration Records- medications were observed to be documented properly and given as prescribed.
  • During the visit conducted on 8/30/23, LPA observed R1's bed to have half bed rails and R2's bed to have full bed rails. Resident files reviewed that day contained proof of written orders from their physician's indicating the need for the rails.
  • (2) staff interviews were conducted
  • (4) client interviews were conducted


Per California Code of Regulations, Title 22, no deficiencies were observed during today's visit.

An exit interview was conducted with DSP Eadgitha Manalad, and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023
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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