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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320046
Report Date: 03/11/2026
Date Signed: 03/11/2026 04:01:03 PM

Document Has Been Signed on 03/11/2026 04:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:DROCK HOME CAREFACILITY NUMBER:
198320046
ADMINISTRATOR/
DIRECTOR:		ADAMSON RUKAYATFACILITY TYPE:
740
ADDRESS:1652 E CYRENE DRIVETELEPHONE:
(310) 997-8046
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 6CENSUS: 5DATE:
03/11/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:23 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
04:05 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
On 03/11/26 Licensing Program Analyst (LPA) Villegas conducted an unannounced annual inspection visit. LPA met with Rukayat Adamson as the purpose of today’s visit was explained. The facility is licensed to serve (6) residents ages 60 and over of which 6 may be non-ambulatory. There is a hospice waiver for (4). The facilities annual fees are current, facility does not handle residents cash resources, Administrator certificate is pending (payment submitted), liability insurance is active (0100428328-0 EXP: 2/6/27)

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (3) resident bedrooms, (2)staff bedrooms, (1) resident bathroom, (1) staff bathroom, living room, dining room, kitchen, attached (2) car garage, and back yard patio with table and 6 chairs. Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 114 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to residents, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of (2) staff records, (5) resident records, and (5) medication administration records. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted in January 2026, 1 fire extinguisher fully charged, carbon monoxide and smoke detectors are operational.

Deficiencies cited on 809D page.

Exit interview conducted, appeal rights explained, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Lizeth Villegas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2026
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 03/11/2026 04:01 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 03/11/2026 at 03:19 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: DROCK HOME CARE
FACILITY NUMBER: 198320046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
The medical assessment shall include, but not be limited to:
A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following:
Communicable tuberculosis.


Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as resident #1 (R1) is missing a health screening with proof of negative TB test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
1
2
3
4
Licensee to submit health screening (LIC 503) with negative TB test results by POC due date.
Lizeth.villegas@dss.ca.gov
Type B
Section Cited
CCR
87457(c)(1)(A)
87457 Pre-Admission Appraisal
Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.
The appraisal shall document, at a minimum:
An evaluation of the prospective resident's functional capabilities, mental condition, and social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factor.
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as residents #1-5 (R1-R5) do not have a needs and service plan in their file for LPA to review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
1
2
3
4
Licensee to complete a needs and service plan for all residents and submit a copy to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Lizeth Villegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/11/2026 04:01 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 03/11/2026 at 03:23 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: DROCK HOME CARE
FACILITY NUMBER: 198320046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
87411 Personnel Requirements - General All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as Staff #1 (S1) did not have a health screening with proof of negative TB test for LPA to review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
1
2
3
4
Licensee to provide LPA with proof of health screening with a negative TB test completd and signed by a physician by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Lizeth Villegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/11/2026 04:01 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 03/11/2026 at 03:35 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: DROCK HOME CARE
FACILITY NUMBER: 198320046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)(1)
87208 Plan of Operation
The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:
Statement of purposes and program goals.
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as facility currently has dog(s) in the backyard which is not part of their approved paln of operation. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
1
2
3
4
Licensee to submit an updated plan of operation detailing what is the purpose and program goals of having the Dog(s) at the facility. If the licensee does not wish to update the plan of operation, licensee shall provide proof to LPA by POC due date that the dog(s) have been relocated.
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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Lizeth Villegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 5 of 5