198320401-10-20-2023-11-AS-LVIS-CWST8A-20231020143000

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320401
Report Date: 10/20/2023
Date Signed: 10/20/2023 02:30:08 PM

Document Has Been Signed on 10/20/2023 02:30 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	TABITHA CARE II		FACILITY NUMBER:	198320401
ADMINISTRATOR:	ADELEKE, OMOBOLA		FACILITY TYPE:	735
ADDRESS:	20 EAST MARKET STREET		TELEPHONE:	(626) 639-9186
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90805
CAPACITY: 4		CENSUS: 0	DATE:	10/20/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Director Omobola Adeleke		TIME COMPLETED:	03:18 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/20/23 at 12 pm Licensing Program Analyst (LPA) Villegas conducted an announced visit to the facility for purpose of a pre-licensing evaluation, LPA met with Director Omobola Adeleke. An application was submitted to CCLD on August 18^th, 2023, for Initial license for an Adult Residential Facility for developmentally disabled adults ages 18 to 59. There is a fire clearance for four (4) ambulatory clients. Fire clearance approved on July 17^th, 2023, surety bond obtained on April 13^th, 2023, and a residential infection control plan has been submitted. Facility is a single-story home located in a residential neighborhood and consist of the following: (3) client bedrooms, (2) bathrooms of which 1 is shared and 1 is private, living room, dining area, a kitchen, an outdoor laundry area, a shaded area with two locked cabinets used for toxins and additional storage space. No bodies of water nor firearms are on the property. The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation. Passageways, walkways, driveways, steps, and patios are free from obstructions. The client bedrooms are spacious and will easily accommodate the client's furnishings. Beds have the required linen/supplies which include pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen and hygiene products stored in a cabinet in the dining area. Chairs, lamps and dressers were all observed in addition to closet space. Posted & readily available for review in den area is the emergency disaster plan, emergency phone

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TABITHA CARE II	FACILITY NUMBER: 198320401
	VISIT DATE: 10/20/2023

NARRATIVE

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numbers, menu, clients rights, administrator certificate and visitors policy. One (1) fire extinguisher is mounted in kitchen and a second extinguisher is located under the kitchen sink. Smoke and carbon monoxide detectors are interconnected and are operational. A landline and internet service were observed. Dishes, cups, and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked drawer in the kitchen area. Stove burners, microwave, refrigerator, and freezer are all operational. Refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezers are at (0) zero degrees F. and water temperatures measured between 105-120 degrees F.

A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in a locked drawer in the living room, available for staff use but inaccessible to clients. Cash resources will be locked and stored with P & I Ledger, accessible to designated staff, along with staff and client records which shall be stored in a locked cabinet in the dining area and the section has been inspected.

Component III was conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted with Director Omobola Adeleke, and a copy of this report has been provided. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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