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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005668
Report Date: 12/16/2024
Date Signed: 12/16/2024 11:43:05 AM

Document Has Been Signed on 12/16/2024 11:43 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ROLLING HILLS GUEST HOMEFACILITY NUMBER:
306005668
ADMINISTRATOR/
DIRECTOR:		MIRABUENO, MARIA PRICILLAFACILITY TYPE:
740
ADDRESS:1000 ROLLING HILLS DRIVETELEPHONE:
(213) 446-1695
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY: 6CENSUS: 6DATE:
12/16/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Caregiver Lanie PangilinanTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On December 16, 2024, at 8:55 am, Licensing Program Analyst (LPA) Edward Kim conducted a continuation visit for a required 1-year annual visit that was started on December 3, 2024. LPA Kim were greeted and gained entry to the facility by Caregiver (CG) Lanie Pangilinan. LPA Kim spoke over the phone with Administrator (AD) Maria Pricilla Mirabueno and AD Mirabueno said that she could not attend today's visit and said that CG Pangilinan can sign on her behalf for the report.

LPA Kim conducted a record review of staff files and medication review that were in order and complete. First aid kit contained all the necessary elements. The facility has a video teleconferencing device. All smoke detectors and carbon monoxide detectors were operable. LPA Kim conducted two (2) staff interviews, and five (5) resident interviews.

No deficiencies were cited at the time of visit.

An exit interview was conducted and a copy of this report was provided to Caregiver Lanie Pangilinan.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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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