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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608164
Report Date: 08/12/2025
Date Signed: 08/18/2025 08:12:01 AM

Document Has Been Signed on 08/18/2025 08:12 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ROLYN HOMEFACILITY NUMBER:
197608164
ADMINISTRATOR/
DIRECTOR:		RONALD MANALADFACILITY TYPE:
740
ADDRESS:10622 LEEDS STREETTELEPHONE:
(562) 868-1560
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 6CENSUS: 2DATE:
08/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Eadigtha Manalad, Lead StaffTIME VISIT/
INSPECTION COMPLETED:
01:00 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) Daniel Konishi conducted a required unannounced annual inspection using the Inspection Tool. LPA met with Lead Staff, Eadgitha Manalad and the purpose of the visit was discussed. Staff #1 (S1) assisted in the tour of the facility. LPA met with Ronald Manalad shortly after and LPA explained the purpose of the visit.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit, today’s visit and the initial visit and observed the following:

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA observed that the facility has an infection control plan in place.

Operational Requirements:

Fire clearance was approved by LA County Fire Department for six (6) residents, four (4) of which can be non-ambulatory. Liability Insurance is confirmed and currently on file.



Physical Plant/Environment Safety:

LPA conducted a tour of the facility with S1 and observed the following:
The facility is part of a single-story home located in a residential area and contains the following: living room, TV room, dining room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, (4) resident rooms, (2) bathroom for residents, toilet and washbasin, and A back yard with shaded area and seating for resident use.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2025
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 5
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)
Page: 2 of 5
Document Has Been Signed on 08/18/2025 08:12 AM - It Cannot Be Edited


Created By: Daniel Konishi On 08/12/2025 at 12:24 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: 08/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, LPA observed that Resident #1 (R1's) file did not have an updated medical assessment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2025
Plan of Correction
1
2
3
4
Administrator will send R1's updated medical assessment to the LPA by the POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ROLYN HOME
FACILITY NUMBER: 197608164
VISIT DATE: 08/12/2025
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
26
27
28
29
30
31
32
Physical Plant/Environment Safety [Cont.]:

There’s a laundry area with a washer and dryer. All passageways, walkways, driveway, steps and patio are free from obstructions. The front, back and side areas of the house are free of hazards. Hallway linen closet: Contained plenty of linens, towels, and hygiene products. Beds have the required furniture including bed frames, nightstands, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. Fire extinguisher was observed on hallway last reviewed 05/13/2025. Carbon monoxide detectors are tested and in working condition. Cleaning supplies are kept locked under kitchen sink away from food supplies. Sharps are kept locked in a kitchen drawer. Shared client bathrooms were observed to be clean and contained soap and paper towels. Signs promoting hand washing were observed. Water temperature in this bathroom#1 was measured at 109.0 degrees F and Bathroom #2 was measured at 113.8 degrees F which is in the required 105 – 120 degrees F per Title 22 Regulations.



Staffing:

A total of three (3) full-time staff members provide care and supervision to the residents.

Personnel Records/Staff Training:

Administrator’s certificate is active and effective through 09/10/2025. Three (3) staff files were reviewed for criminal background clearance and training. Staff Files include personnel records, health/TB screenings, employee rights, and 1st Aid/CPR/AED training.



Resident Rights/Information:

Residential Care Facility for the Elderly Complaint Poster (PUB 475) posted on the wall. Residents’ Personal Rights posted on the wall. Facility provides internet access for residents.

Planned Activities:

The facility has planned activities with monthly activity calendar and activity log. Facility has sufficient space to accommodate indoor and outdoor activities that are easily accessible.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ROLYN HOME
FACILITY NUMBER: 197608164
VISIT DATE: 08/12/2025
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
26
27
28
29
30
31
32
Food Service:

The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Incidental Medical and Dental:

Residents are assisted with self-administration of prescription and non-prescription medications. Two (2) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to residents in care. Medications are given according to Physician directions.

Resident Records/Incident Reports: LPA reviewed two (2) resident files containing admission agreements, Physician's Report, medical/functional assessments, TB clearance, Appraisal/Needs and Services Plan, personal rights, and P & I money were reviewed. However, based on record review, LPA observed that Resident #1 (R1) did not have an updated medical assessment in file.

Disaster Preparedness:

A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed. An emergency drill was conducted in 06/01/2025. No manual restraints or seclusions are used in residents in care.

Residents with Special Health Needs: There are no residents with postural support at this facility. The facility is free from odors of incontinence.

LPA interviewed two (2) staff and LPA attempted to interview two (2) residents but LPA was unable to interview the two (2) residents since both residents were unable to answer questions on the day of the visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the as provided to the Lead Staff, Eadgitha Manalad.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5