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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320046
Report Date: 05/14/2022
Date Signed: 05/16/2022 08:29:59 AM

Document Has Been Signed on 05/16/2022 08:29 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:
05/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Rukayat AdamsonTIME COMPLETED:
12:15 PM
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On 05/14/22, at 10:15 am, Licensing Program Analyst (LPA)/ Susan Campos conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA was allowed entry into the facility by Rukayat Adamson, Administrator. LPA met with licensee and administrator Rukayat Adamson and explained the purpose of the visit. The facility is licensed to operate residents age range 60 and over, six (6) ambulatory of which 6 may be non-ambulatory and hospice waiver for 4. Last fire drill conducted on 4/26/22.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: 5 bedrooms ( three (3) resident bedrooms and 2 staff rooms), (2) bathrooms ((1) staff and (1) resident bathroom), living room, dining room, kitchen, attached two car garage, and back yard patio with table and six chairs. Each resident bedroom has two residents residing. LPA toured the physical plant with Administrator Ms. Adamson. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The hot water temperature measured 105.9 degrees Fahrenheit. A comfortable temperature of 73 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The fire extinguisher is charged. The smoke detectors and carbon monoxide are operable. Fire Drills were observed to be maintained in order and accurate.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2022
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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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
VISIT DATE: 05/14/2022
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs were reviewed.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Administrator Rukayat Adamson.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2022
LIC809 (FAS) - (06/04)
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