331881729-2-12-2026-18-AS-VFLS-DR8NVE-20260212094748

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881729
Report Date: 02/12/2026
Date Signed: 02/12/2026 09:49:03 AM

Document Has Been Signed on 02/12/2026 09:49 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 VILLA LLC		FACILITY NUMBER:	331881729
ADMINISTRATOR/ DIRECTOR:	OKORO, GERTRUDE		FACILITY TYPE:	740
ADDRESS:	42010 THOROUGHBRED LN.		TELEPHONE:	(951) 691-8004
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92562
CAPACITY: 6		CENSUS: 0	DATE:	02/12/2026
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Administrator Gertrude Okoro		TIME VISIT/ INSPECTION COMPLETED:	10:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 2/12/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an announced prelicensing visit to the facility. LPA was greeted and was granted entry into the facility by Applicant Gertrude Okoro. A tour of the facility was conducted alongside Gertrude. The following was observed during today's visit: The facility is a single-story structure which consisted of (3) three resident bedrooms, (2) two bathrooms, living room, dining room, kitchen, laundry room, garage, and gated backyard. All indoor/outdoor passageways were observed to be free from obstruction. Night lights were maintained in the hallways that led to non-private bathrooms. Resident bedrooms were equipped with the required bedding, furniture, seating and functional lighting. Bathrooms were inspected; LPA observed grab bars near the toilet area and inside the shower. There was slip resistant material maintained on the flooring of the shower. LPA observed (2) fully charged fire extinguishers mounted on the walls throughout the facility. Smoke and carbon monoxide detectors were observed and deemed to be fully operable. Activities were observed to be stored in the living room. Kitchen area was organized and sanitary. LPA observed a (2) two-day supply of perishable foods and (7) seven-day supply of non-perishables. Knives and other sharp items were stored in a locked cabinet, inaccessible to potential residents. The Applicant anticipates to operate their own laundry services. Washer and dryer were observed to be fully operable. LPA observed a locked cabinet which will store cleaning supplies and other disinfectants. Medication will be centrally stored in a locked closet. The outdoor area was sufficient is space to promote outdoor activities. LPA observed a covered patio that was furnished. Per Applicant, there are no firearms and/or ammunition on the premises. (Continue to LIC809C...)

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Valerie Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

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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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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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 VILLA LLC	FACILITY NUMBER: 331881729
	VISIT DATE: 02/12/2026

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(Continuation from LIC809...)

LPA observed the required posting of the LTCO, PUB475, Employee Rights, Resident Personal Rights, Administrator Certification, Emergency Disaster Plan, and Facility Sketch.

LPA Flores has determined the facility meets the operational requirements for licensure. Final approval of licensure will be determined by the Centralized Application Bureau (CAB). The prelicensing inspection is complete and has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted, and a copy of this report was discussed and provided to Applicant.

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Valerie Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026

LIC809 (FAS) - (06/04)

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