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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320206
Report Date: 12/19/2024
Date Signed: 01/06/2025 02:02:40 PM

Document Has Been Signed on 01/06/2025 02:02 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:234TH HOMEFACILITY NUMBER:
198320206
ADMINISTRATOR/
DIRECTOR:		BOATNER, VERRETTAFACILITY TYPE:
735
ADDRESS:160 E. 234TH STREETTELEPHONE:
(310) 872-3326
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 4DATE:
12/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Ebeagbor EmuobonuvieTIME VISIT/
INSPECTION COMPLETED:
11:59 AM
NARRATIVE
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On 12/19/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced Case Management visit at this facility. The program Supervisor, Ebeagbor Emuobonuvie, greeted LPA. LPA explained to Emuobonuvie that the visit was associated with an incident on 11/17/24.

On 11/17/24, Program Supervisor Ebeagbor Emuobonuvie reported an incident concerning client #1 (C1) and staff #1 (S1) alleging improper relationships between client and staff. LPA Dabuet interviewed the program supervisor staff #2 (S2) Ebeagbor Emuobonuvie and staff #3 (S3) regarding the incident involving (C1) and (S1). Interviews with client between client #1 (C1) and (S1) was found by (C1) sleeping on the job.

An Unusual Incident Report LIC 624 (dated 12/12/24) was reported during an ongoing investigation conducted with Harbor Regional Center Quality Assurance and California Mentor Quality Improvement Specialist involving staff #1 (S1) sleeping on the job. While on the NOC shift, staff #4 (S4), validated by staff #1 (S1), reported (S1) to be constantly asleep. Additionally, (S1) admitted to sleeping on the couch in the common area during the NOC shift.

On 12/19/24, between 10:30 a.m. and 11:00 a.m., LPA Dabuet interviewed client #2 (C2), who reported having observed (S1) asleep on the job multiple times on the couch in the common area.

Based on evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF SUPERVISION is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed, and a citation has been issued (ref. LIC 809-D). 

An exit interview was conducted, and Program Supervisor Ebeagbor Emouobonuvie was provided with a copy of the report and Appeal Rights.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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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Document Has Been Signed on 01/06/2025 02:02 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 12/19/2024 at 11:21 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: 234TH HOME
FACILITY NUMBER: 198320206

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/02/2025
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision (a)The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement is not met as evidenced by:
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Licensee is to review Title 22 Regulation Section 80078, Licensee is to review Title 22 Regulation Section 8506.5.6 Night Supervision and submit a plan to retrain all staff on DSP responsibilities and duties. POC is to be submitted to LPA Dabuet at ernand.dabuet@dss.ca gov by 01/02/25.
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Based on interview and record review, Licensee failed to meet the client's needs of care and supervision during NOC shift with evidence of staff #1 sleeping on the job. This violation poses a potential health and safety risks to clients 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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


LIC809 (FAS) - (06/04)
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