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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320046
Report Date: 03/25/2022
Date Signed: 05/18/2022 10:01:19 AM

Document Has Been Signed on 05/18/2022 10:01 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:DROCK HOME CAREFACILITY NUMBER:
198320046
ADMINISTRATOR:ADAMSON RUKAYATFACILITY TYPE:
740
ADDRESS:1652 E CYRENE DRIVETELEPHONE:
(310) 997-8046
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 6CENSUS: 6DATE:
03/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:53 PM
MET WITH:Rukayat AdamsonTIME COMPLETED:
05:00 PM
NARRATIVE
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This report serves as an amendment to report created on 3/25/2022 . This report supersedes the case management complaint investigation findings reflected on LIC 809 report created on 3/25/2022.

On 3/25/22, at 3:52 pm, Licensing Program Analyst/ LPA Campos conducted a case management visit. LPA was allowed entry to the facility by Administrator Rukayat Adamson. LPA Campos explained to Ms. Adamson the purpose of the visit.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.

Exit interview conducted with Administrator Adamson.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
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 05/18/2022 10:02 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/14/2022 08:51 AM


Created By: Susan Campos On 03/25/2022 at 04:06 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: DROCK HOME CARE
FACILITY NUMBER: 198320046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)

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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Susan Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022


LIC809 (FAS) - (06/04)
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