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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320401
Report Date: 08/09/2024
Date Signed: 08/23/2024 10:11:31 AM

Document Has Been Signed on 08/23/2024 10:11 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:TABITHA CARE IIFACILITY NUMBER:
198320401
ADMINISTRATOR/
DIRECTOR:		ADELEKE, OMOBOLAFACILITY TYPE:
735
ADDRESS:20 EAST MARKET STREETTELEPHONE:
(626) 639-9186
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY: 6CENSUS: 5DATE:
08/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:21 AM
MET WITH:ADELEKE, OMOBOLATIME VISIT/
INSPECTION COMPLETED:
11:40 AM
NARRATIVE
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On 08/09/24, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Director ADELEKE OMOBOLA as the purpose of the visit was explained. The facility is licensed to serve six (6) ambulatory only adults ages 18-59. Current census us (5), facility fees info was provided.

Facility is a single-story home located in a residential neighborhood and consist of the following: (3) client bedrooms, (2) bathrooms, living room, dining area, a kitchen, an outdoor laundry area, a shaded area with two locked cabinets used for toxins and additional storage space. The facility has board games, books, and other recreational materials for the client's use.



Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to clients, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of 2 staff records, 5 client records, and 2 medication administration records, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 06/06/24, 2 fire extinguisher fully charged, carbon monoxide and smoke detectors are interconnected and operational.

deficiencies cited on 809D

Exit interview conducted with Director, appeal rights explained, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2024
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 08/23/2024 10:11 AM - It Cannot Be Edited


Created By: Lizeth Villegas On 08/09/2024 at 11:19 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: TABITHA CARE II
FACILITY NUMBER: 198320401

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
80070 Client Records

The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as client #1-5 are missing the following documents in their files; emergency I.D. form (facesheet), needs and service plan, personal rights (LIC 613), consent forms, and safeguard of property valuables which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Director to gather, complete and file the documents listed above for client #1-5. Director to submit proof to LPA Villega by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024


LIC809 (FAS) - (06/04)
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