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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320401
Report Date: 10/03/2024
Date Signed: 10/03/2024 12:19:23 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/25/2024 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20240925150406
FACILITY NAME:TABITHA CARE IIFACILITY NUMBER:
198320401
ADMINISTRATOR:ADELEKE, OMOBOLAFACILITY TYPE:
735
ADDRESS:20 EAST MARKET STREETTELEPHONE:
(626) 639-9186
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY:6CENSUS: 7DATE:
10/03/2024
UNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Aministrator Omobola AdelekeTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility operated beyond the terms of the license.
INVESTIGATION FINDINGS:
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On 10/03/2024 Licensing program analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation above. LPA met with Administrator Omobola Adeleke as the purpose of the visit was explained.

The investigation consisted of the following: On 10/03/24 LPA obtained copies of staff and client rosters, toured the facility, and conducted interviews with Administrator (AD), staff #1 (S1), and clients # 2-3 (C2-C3).

The investigation revealed the following:
Allegation: Facility operated beyond the terms of the license.
It is being alleged that the facility is housing more clients then they are licensed to have. On 10/03/24 LPA conducted interview with AD regarding the allegation above, AD confirmed the allegation above and stated there have been a total of 7 clients at the facility. On 10/03/24 LPA conducted interview with S1 regarding the allegation above, 1 of 1 staff interview reported having no knowledge regaring the allegation above.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 11-AS-20240925150406
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: TABITHA CARE II
FACILITY NUMBER: 198320401
VISIT DATE: 10/03/2024
NARRATIVE
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On 10/03/24 LPA conducted interviews with C2-C3, 1 of 2 clients interviewed reported having no knowledge regarding the allegation above, 1 of 2 clients interviewed confirmed the allegation above and reported facility has been over capacity. On 10/03/24 LPA conducted a tour of the facility and observed 3 twin beds located in bedroom #3. On 10/03/24 LPA reviewed LIC 9020 and observed only 6 clients listed, AD reported the LIC 9020 has not been updated to reflect the census of 7.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D.

Exit interview conducted, appeal rights explained, and a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20240925150406
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: TABITHA CARE II
FACILITY NUMBER: 198320401
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2024
Section Cited
CCR
80010(a)
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80010Limitations on Capacity and Ambulatory Status
A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.
This requirement is not met as evidenced by:
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Licensee/Administrator will review Title 22 Sec. 80010 to ensure facility remains in compliance. Licensee will submit a plan on how facility will remain in capacity and in compliance.
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Based on record reviews, observation, and interviews, the licensee did not comply with the section cited above. The licensee has 7 clients in care which is over the approved capacity of facility license. This violation poses a potential health, safety, or personal rights risk to persons 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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3