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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006133
Report Date: 10/19/2023
Date Signed: 10/19/2023 11:39:35 AM

Document Has Been Signed on 10/19/2023 11:39 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: 4DATE:
10/19/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:17 AM
MET WITH:Jeff BencitoTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced Plan of Correction (POC) visit to follow up on citation issued on 10/02/2023. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Jeff Bencito arrived during the visit.

*Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Centrally Stored Medications has been cleared. Medications are secured during today's visit. Licensee has complied with the POC.


Advisory note dated 10/02/2023 indicated the following:
  • The front left burner on stove top is inoperable. Please repair/ replace.
  • Emergency food supply appears low. Please ensure there is enough emergency food for all staff/ residents for at least 72 hours.

During the visit, LPA observed facility replaced the stove and all burners work as well as an ample emergency food and water supply.


Licensee has been advised to maintain compliance in all items previously cited.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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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