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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880541
Report Date: 12/30/2025
Date Signed: 12/31/2025 09:33:28 AM

Document Has Been Signed on 12/31/2025 09:33 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ROLLING GREEN SENIOR CAREFACILITY NUMBER:
331880541
ADMINISTRATOR/
DIRECTOR:		OKORO, GERTRUDEFACILITY TYPE:
740
ADDRESS:42007 THOROUGHBRED LNTELEPHONE:
(951) 397-3369
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY: 6CENSUS: 4DATE:
12/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:staff Florence EzehTIME VISIT/
INSPECTION COMPLETED:
05:55 PM
NARRATIVE
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On 12/30/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced 1-year required annual inspection. LPA met with staff Florence Ezeh and explained to Florence the purpose of the visit. LPA was granted entry and conducted a tour of the facility. LPA observed the following during today's visit:

The facility is a single-story structure which consisted of (2) two staff bedrooms, (3) three resident bedrooms, (2) two bathrooms, living room, kitchen, garage, laundry room, and backyard. The backyard was observed to have a covered patio that was fully furnished. Indoor/outdoor passageways were free from obstructions. Facility maintained a (2) two-day supply of perishable foods but did not maintain a (7) seven-day supply of non-perishable foods. Kitchen was kept clean and free of vermin. Perishable foods observed were not of nutritional value; perishable foods maintained were of processed food items. Knives and other sharp materials were stored in a locked cabinet in the kitchen. LPA observed an unlocked cabinet which stored disinfectants and other cleaning solutions. LPA was informed that the cabinet is kept unlocked until the end of the day. Medication was centrally stored in a locked cabinet in the hallway. Resident bedrooms were equipped with the required bedding, furniture, and functional lighting. Shower and toilet area was equipped with the required grab bars and shower was equipped with a slip resistant material. LPA observed activities available for residents like books, puzzles, and games. The dual carbon monoxide and smoke detectors were tested and observed to be fully operable. LPA observed a cabinet in the hallway which stored additional linen and towels. LPA observed a fully functioning washer and dryer to provide residents with laundry services.

(Continue to LIC809C)
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Valerie Flores
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2025
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 6
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)
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Document Has Been Signed on 12/31/2025 09:33 AM - It Cannot Be Edited


Created By: Valerie Flores On 12/30/2025 at 03:38 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ROLLING GREEN SENIOR CARE
FACILITY NUMBER: 331880541

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and records review, the licensee did not comply with the section cited above in (1) one of (2) two staff did not have the required completed (20) hour annual training which poses a potential health, safety or personal rights risk to residents in care.
POC Due Date: 01/13/2026
Plan of Correction
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Training's will be completed by 01/13/2026 but cannot be use to supplement the required training for 2026. Proof of completion will be forwarded to LPA via email by Close of Business on 1/13/2026.
Type B
Section Cited
CCR
87468.2(a)(5)
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (5) To be served food of the quality and quantity necessary to meet their nutritional needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interview, the licensee did not comply with the section cited above as facility maintained the (2) day supply of perishable foods but foods lacked of nutritional value. Lacking fresh produce and maintained a high quantity of processed meals which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2025
Plan of Correction
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Licensee will provide proof of grocery store receipt reflecting the purchase of the perishable foods of nutritional value by 12/31/2025, along with an updated meal and snack calendar of meal and snack being served to the residents. The calendars are to be created weekly for one month and submitted to LPA to ensure compliance, forwarded to LPA, and stored in a file at the facility for the departments review. POC will not be fullfilled until facility demonstrates compliance.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Valerie Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ROLLING GREEN SENIOR CARE
FACILITY NUMBER: 331880541
VISIT DATE: 12/30/2025
NARRATIVE
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(Continuation from LIC809)

Facility maintained a facility cellphone that connected to the internet and equipped with a camera for resident-use. Per staff Florence, there are no firearms and/or ammunition on the premises.

LPA conducted (4) four out of (4) four resident records review. Records review included but not limited to dental information, pre-placement assessments, admission agreements, physician reports, and needs and service plans. LPA conducted a review of (2) two out of (2) two staff records. Records included but not limited to fingerprinting, background clearance, personnel report, health screening, TB results and first-aid/CPR certification. LPA did not observe (20) twenty hours of annual training for Staff #1 (S1). Upon speaking with S1, LPA was advised that the training's had not been completed due to lack of time. LPA observed postings of the LTCO, See Something Say Something, Personal Rights, Emergency Disaster Plan, Facility License, and Administrator Certification.

During today's visit, LPA observed multiple health and safety concerns. Therefore, deficiencies will be issued in accordance with Title 22 Division 6.

An exit interview was conducted and a copy of this report was provided to staff Florence, along with LIC 9099C, (2) LIC9099D, and appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Valerie Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 12/31/2025 09:33 AM - It Cannot Be Edited


Created By: Valerie Flores On 12/30/2025 at 04:29 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ROLLING GREEN SENIOR CARE
FACILITY NUMBER: 331880541

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above as LPA observed an unlocked cabinet while conducting a tour of the facility which stored disinfectants, and other cleaning solutions which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/13/2026
Plan of Correction
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The cabinet was immediately locked and made inaccessible to residents. Completion of an RCFE safety training from an outside provider will be submitted to LPA by Close of Business on 1/13/2026 via email. Training must be completed by all staff.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Valerie Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2025


LIC809 (FAS) - (06/04)
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