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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507208788
Report Date: 06/25/2021
Date Signed: 06/25/2021 12:36:41 PM

Document Has Been Signed on 06/25/2021 12:36 PM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ROWENA'S HOME CARE 2FACILITY NUMBER:
507208788
ADMINISTRATOR:PABLO, ROWENA MFACILITY TYPE:
740
ADDRESS:6107 TERMINAL AVENUETELEPHONE:
(808) 429-0253
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY: 6CENSUS: 6DATE:
06/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Rowena PabloTIME COMPLETED:
12:55 PM
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On 06/23/2021 at 8:27am, Licensing Program Analyst (LPA) Ashley Boothe spoke with Licensee, Rowena Pablo regarding facility risk assessment questions. Rowena confirmed no staff or residents have experienced symptoms within the last 10 days. At 10:45am, LPA arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Rowena and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 5 non ambulatory and 1 bedridden residents and hospice waiver for 4 in compliance with fire clearance and license. Today's census is 6 of which 3 are hospice. Four of four staff observed with criminal record clearance and associated in Licensing Information System. LPA observed Administrator Certificate expires 8/2/2023.

LPA interacted with a random number of residents during this visit and observed residents engaging in activities and dining. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed kitchen, restrooms, bedrooms, laundry room, storage areas and common living areas to be clean in good repair. The temperature inside the facility was measured at 78*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30*F less than the outside temperature. One of four residents rooms was warmer than other rooms measured at 85*F. LPA provided technical assistance to purchase an additional fan or portable air conditioner to maintain the temperature in the room. The hot water was measured at 112.5 *F which is not less than 105 *F and not more than 120*F. LPA observed the centrally stored medications, knives, kitchen, laundry and staff room to be locked inaccessible to residents. All medications observed properly stored and labeled. The first aid kit was found in compliance containing at least the following: a current edition of approved first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ROWENA'S HOME CARE 2
FACILITY NUMBER: 507208788
VISIT DATE: 06/25/2021
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LPA observed fire extinguisher last inspected on 1/8/2021, pull alarm, smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed food supplies of properly stored and unexpired staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed COVID precautions signs posted, restrooms stocked with paper towels, hand soap and touchless covered trash can and 30 day supply of PPE stored.

LPA reviewed two resident files. Resident one (R1) diagnosed Dementia last medical assessment due 5/2021 appointment scheduled for 7/2021. Resident two (R2) diagnosed Dementia last medical assessment completed 3/2021.

Upon a file review the following items were discussed to be submitted with any changes annually to LPA by 7/15/2021.

Criminal Record Clearances LIS536
Administrative Organization LIC309
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Liability Insurance
Administrator Certificate
Emergency Disaster Plan LIC610E
First aid/CPR certificates

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report provided. A signature on these forms acknowledges receipt.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
LIC809 (FAS) - (06/04)
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