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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320206
Report Date: 11/22/2024
Date Signed: 11/22/2024 09:54:38 PM

Document Has Been Signed on 11/22/2024 09:54 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:
11/22/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:27 PM
MET WITH:Ebeagbor EmuobonuvieTIME VISIT/
INSPECTION COMPLETED:
04:17 PM
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On 11/22/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced Case Management visit at this facility. LPA was greeted by the Program Supervisor Ebeagbor Emuobonuvie. LPA explained to Emuobonuvie the visit is associated with an incident on 10/23/24.

On 10/23/24, Program Supervisor Ebeagbor Emuobonuvie reported an incident concerning client #1 (C1) while visiting family members, (C1) may have been in possession of illegal drugs, taken money without consent and threaten a family member. LPA Dabuet interviewed the program supervisor staff #1 (S1) Ebeagbor Emuobonuvie and staff #2 (S2) regarding the incident involving (C1). (C1) was not available for an interview as well as clients #3 and #4 who were all out in the community.

A separate investigation is conducted by Harbor Regional Center Quality Assurance Department.

LPA Dabuet requested copies of (C1's) Physicians Report LIC 602 (dated: 09/10/24), Face Sheet Information, Applied Behavior Analysis Consultation Report (dated: 8/27/24).

An exit interview conducted with Ebeagbor Emuobonuvie, and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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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