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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507208788
Report Date: 06/10/2022
Date Signed: 06/10/2022 01:18:40 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/10/2022 01:18 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:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rowena PabloTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual visit. LPA Jensen met with Licensee Rowena Pablo and explained the purpose of today's visit. The administrator holds a valid and current administrator certificate # 6036268740 that is good through 8/2/23.

The facility is a single story building with a centrally designated entry point. The facility is licensed for 6 residents and has 5 bedrooms with one bedroom designated for double occupancy. The entry point was observed to be equipped with COVID screening log, digital thermometer, visitor sign in sheet, infection control signage, sanitizer and PPE.

Sigange throught the facility included all regulatory required postings prominently displayed and in the correct size. LPA Jensen observed all staff wearing masks. LPA Jensen toured the facility including but not limited to living room, dining room, kitchen, laundry room, office, bedrooms and bathrooms. The facility had adequate lighting and furniture for the comfort of residents in care. LPA Jensen interacted with 2 residents during the course of the visit. The temperature in the facility was 78 degrees which falls within the required range of 68-85 degrees. The first aid kit was observed to be complete including but limited to scissors, thermometer, tweezers, gauze, bandages and 1st aid manual. Toxins, medications and sharp objects were observed to be locked and inaccessible to residents. The kitchen was observed to be clean and sanitary. There was in excess of 7 day supply of non-perishable food and 2 day supply of perishable food. LPA observed adequate fruits and vegetables for meal service.

The fire extinguisher was last serviced on 1/22/22 and is in compliance. LPA observed 2 carbon monoxide detectors which were tested and found to be in good working order.


Continued on 809C......
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
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: 06/10/2022
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The resident bathroom temperature was measured at 110.2 degrees in one bathroom and 113.8 degrees in a second bathroom which falls within the required range of 105 degrees to 120 degrees. There is laminate flooring and tiles throughout the facility. A transition strip leading to the bathroom was observed to be loose. The shower head in a resident bathroom was observed to be separating from the wall. A recessed light in a bedroom was observed to be missing a component.

Two staff files were reviewed and were observed to be complete and organized. All first aid certificates were verified as being current. All staff are vaccinated and boosted against COVID-19.

The grounds were observed to be maintained and cleared of debris with easily accessible fire escape routes.

Deficiencies were observed and cited on the LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code.

An exit interview was conducted and a copy of this report was provided to Licensee along with appeal rights.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/10/2022 01:18 PM - It Cannot Be Edited


Created By: Maja Jensen On 06/10/2022 at 12:52 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ROWENA'S HOME CARE 2
FACILITY NUMBER: 507208788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2022
Section Cited
CCR
80087(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement was not met as evidenced by:
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Licensee agrees to repair the transition strip, shower head and recessed lighting and will submit photos by email to maja.jensen@dss.ca.gov by 6/24/22.
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Based on LPA's observation of a shower head separating from the wall, a broken transition strip and recessed light fixture missing a component. This poses a potential health and safety risk to resident in care.
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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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022


LIC809 (FAS) - (06/04)
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