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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006133
Report Date: 08/16/2022
Date Signed: 08/16/2022 11:48:42 AM

Document Has Been Signed on 08/16/2022 11:48 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HILLS OF ROCKAWAY, THEFACILITY NUMBER:
306006133
ADMINISTRATOR:MEDINA, ALLENFACILITY TYPE:
740
ADDRESS:919 E ROCKAWAY DRIVETELEPHONE:
(909) 450-1699
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 6DATE:
08/16/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Allen MedinaTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs) Claudia Gutierrez and Michelle Reed made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPAs arrived at the facility and were greeted and granted entry by Administrator (AD) Allen Medina. LPAs temperature was checked upon entry and a hand sanitizing station was observed. An application to operate a Residential Care Facility for Elderly (RCFE) for a capacity of 6 non-ambulatory residents of which 1 may be bedridden was received on 1/10/2022 by Community Care Licensing (CCL).

Structure:
The facility is a one-story home with 4 resident bedrooms, 2 bathrooms, living room, kitchen, staff break room, and an attached two car garage. In the backyard there. LPAs observed the Ombudsman and the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the dining area. LPA observed there are door alarms on the front door and all exit doors. There is a back yard with one exit gate on the side of the house and has an auditory alarm. LPA tested the door alarm and it was operational. There is a shaded seating area in the backyard. No bodies of water observed. LPAs did not observe any obstacles or hazards in the backyard.

Client Bedrooms
All client bedrooms had the required furnishings. LPAs observed all resident beds had linens and blankets. LPAs observed all windows were screened.

Signal system
Residents have individual pendants to alert staff.

Toxins:


All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked in the supply closet.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HILLS OF ROCKAWAY, THE
FACILITY NUMBER: 306006133
VISIT DATE: 08/16/2022
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Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was posted and visible. Emergency food is stored in the garage.

Food Service:
There is a supply of 2-day perishable and 7-day of non-perishable food on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas five burner stove with 1 oven, 2 refrigerators, dish washer, microwave, washer, and dryer are operational.

The AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. LPAs informed the applicant's representative that once the facility is licensed a post licensing visit will be conducted within 90 days of licensure. Exit interview was conducted and a copy of this report was provided to AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HILLS OF ROCKAWAY, THE
FACILITY NUMBER: 306006133
VISIT DATE: 08/16/2022
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Medications, First-Aid Kit & Book:
Medication will be stored in a locked cabinet. First aid kit is stored with the medication. The first aid kit has all the required elements.

Resident & Staff Files:
Records will be kept locked in storage cabinet located in the kitchen.

Pool/Jacuzzi:
No bodies of water in facility.

Fire Extinguisher:
All fire extinguishers are fully charged.

Reading Material, Games, Equipment & Materials:
The facility has books, art supplies and other recreational materials for resident use, stored in the living room. Facility encourages music and outdoor activities such as walks and sitting out in the patio.

Fire clearance:
Was approved by a fire inspector of Orange County Fire Authority on 01/25/2022. Special conditions noted “this is a four bedroom home with no bedroom for the caregivers.”

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bedrooms Staff:


No staff will be living at the facility. There is a bedroom designated as a staff break room.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 111.3 degrees Fahrenheit.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3