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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001093
Report Date: 06/27/2022
Date Signed: 06/27/2022 12:47:16 PM

Document Has Been Signed on 06/27/2022 12:47 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ROCHELLE MANORFACILITY NUMBER:
306001093
ADMINISTRATOR:ALFREDO RINGORFACILITY TYPE:
740
ADDRESS:12841 ADELLE STTELEPHONE:
(714) 537-3188
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 20CENSUS: 15DATE:
06/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Foster RingorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility. LPA met with Administrator Foster (AD) Ringor and stated the purpose of this visit.

On June 22, 2022, Community Care Licensing Division (CCLD) Orange Office received an incident report from this facility indicating that Resident 1 (R1) was observed to have a lump over the right eye. R1 was sent out for medical consult and came back to the facility on the same day.

For this visit, LPA Marin toured the interior and exterior portions of the facility. LPA observed two staff members on the floor with 9 residents in common area and one in the bedroom. 5 residents were out of the facility attending respective day programs. LPA did a file review of R1's visit in the emergency department. LPA discussed with AD California Code of Regulations (CCR) Section 87466 : Observation of the Resident.

For this visit, no citation was issued.

LPA Marin conducted an exit interview with AD Foster Ringor. LPA left copy of this report and CCR 87466 in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
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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