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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610464
Report Date: 02/09/2024
Date Signed: 02/09/2024 10:17:14 AM

Document Has Been Signed on 02/09/2024 10:17 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:UNIQUE GROUP HOMEFACILITY NUMBER:
197610464
ADMINISTRATOR:OMOTAYO, BABATUNDEFACILITY TYPE:
735
ADDRESS:8045 GROVE STTELEPHONE:
(818) 770-2940
CITY:SUNLANDSTATE: CAZIP CODE:
91040
CAPACITY: 4CENSUS: 4DATE:
02/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Babtunde Omotayo, Babatunde OniTIME COMPLETED:
10:30 AM
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Licensing Program Manager (LPM) Eva Miller and Licensing Program Analyst (LPA) Michael Cava conducted a Case Management visit and inspection of the facility to insure compliance since the Change in Ownership application has been approved. The facility caters to level 4 C clients. Facility has a pending application with Regional Center (RC). LPM and LPA met with staff, Babatunde Oni, and explained the reason for the visit. The Licensee/Administrator, Babatunde Omotayo was called and he joined shortly.

At approximately 8:15am, with the assistance of staff, a tour of the physical plant was conducted. The smoke alarms and carbon monoxide detectors are dual, hardwired and interconnected. The fire extinguisher is located in the kitchen.

Kitchen: The kitchen appliances and fixtures were functional. Knives were stored in a locked drawer in the kitchen. Medications were locked in one of the kitchen cabinets. There is one client that requires insulin and blood sugar test. Container for needles and disposable items were kept in another locked drawer in the kitchen.

Bedrooms: There are three (3) bedrooms designated for client use. Bedroom #1 and #2 are private rooms. Bedrooms #3 is designated for staff. Bedroom #4 is a shared room .

Bathrooms: The facility has three (3) bathrooms. Bedroom #1 and #2 residents use the shared hallway bathroom. Staff has it's own bathroom with shower and tub. The other bathroom is in bedroom 4 located at the back of the the facility next to the backyard.

Common Areas: These included the tv and activity room which were equipped with living room furniture, a television, tables and chairs. There is a fireplace with a screen. It is non-operational. No fireplace tools or fixtures present. The dining area has a large dining room table to accommodate all residents.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: UNIQUE GROUP HOME
FACILITY NUMBER: 197610464
VISIT DATE: 02/09/2024
NARRATIVE
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LAUNDRY ROOM/Garage : The laundry room is located in the garage. It is inaccessible to the residents. You will need a code to unlock and gain access.

OFFICE/STAFF WORKSTATION: Staff workstation is located by the tv/activity room. Resident and personnel files will be maintained in a locked filing cabinet there, alongside the medication cart.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. The backyard of the facility has a patio and backyard furniture to accommodate the four (4) residents. The facility backyard has sufficient yard space.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were observed and cited (refer to LIC 809-D).

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
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Document Has Been Signed on 02/09/2024 10:17 AM - It Cannot Be Edited


Created By: Michael Cava On 02/09/2024 at 08:56 AM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: UNIQUE GROUP HOME
FACILITY NUMBER: 197610464

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/09/2024
Section Cited
CCR
80075(k)(1)

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Health Related Services: Medication shall be kept in a safe and locked place that is not accessible. This requirement was not met as evidenced by: During the physical plant inspection, a bottle of Robitussin was observed in the common area. This posses an immediate health & safety risk to clients
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Staff removed and stored the medication immediately during the inspection. No further corrections required.
Type A
02/09/2024
Section Cited
CCR
80087(a)

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Buildings and Grounds: The facility shall be clean, safe, sanitary and in good repair at all times. This requiremet was not met as evidenced by: During inspection, water damage and a hole on the bathroom & closet wall was observed. This posses an immediate health & safety rist to cllients.
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Although the licensee stated this has already been addressed and arrangements were made for repairs, as POC, the licensee will submit pictures and an invoice as proof repairs were made. POC due to the licensing agency by March 9, 2024
Type B
02/10/2024
Section Cited
CCR85076(d)(1)

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Food Service: Supplies of staple nonperishable foods for a minimum of one week shall be maintained on the premises.
This requirement was not met as evidenced by: During inspection, it was observed that the facility lacked an adequate amount of nonperishable canned food items.
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As POC, the licensee will purchase a sufficient amount of canned meat, fruit and vegetable, canned food items to meet regulation. As proof purchase was made, the licensee will submit photos and a receipt to the licensing agency by 02/10/24

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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:Eva Miller
LICENSING EVALUATOR NAME:Michael Cava
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


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