198320548-5-16-2025-11-AS-PBUR-DGQNS5-20250516104233

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320548
Report Date: 05/14/2025
Date Signed: 05/16/2025 10:42:56 AM

Document Has Been Signed on 05/16/2025 10:42 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	TRANQUIL MEADOWS HOME INC.		FACILITY NUMBER:	198320548
ADMINISTRATOR/ DIRECTOR:	BOSORO, ADELEKE AYODELE		FACILITY TYPE:	735
ADDRESS:	411 E HARDY STREET		TELEPHONE:	(951) 231-8909
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90301
CAPACITY: 4		CENSUS: 0	DATE:	05/14/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Adeleke Bosoro		TIME VISIT/ INSPECTION COMPLETED:	04:00 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	Licensing Program Analyst (LPA) Pamela Bunker made an announced visit and met with Applicant Adeleke Bosoro to conduct a Pre-Licensing evaluation. An application was submitted to the Department of Social Services, Community Care Licensing Division (CCLD) on October 08, 2024, for an initial application for Adult Residential for ages 18-59 years. The requested capacity is for six (4) ambulatory. Structure: The facility is a single-story family home located in a residential neighborhood with four (4) bedrooms, two (2) full bathrooms, a living room, a dining room, a kitchen, a laundry room, a garage, a storage house, and an office in the back of the home. The facility features a shaded patio and an indoor/outdoor activity area located at the rear of the house. Two (2) exits are located in the living room, and the back exit door is near the kitchen and laundry room. The front and backyard landscapes were in good condition. Clients' Bedrooms: There shall be no more than two clients per bedroom. Bedrooms #1 and #2 each have a queen-size bed, a dresser, a chair, a nightstand, a lamp, a TV, a closet, and a ceiling fan. Bedrooms #3 and #4 are equipped with one twin-size bed, a chest of drawers, a chair, a nightstand, a lamp, a TV, a closet, and a ceiling fan. Staff Bedroom: There will be no living staff. Bathrooms: The bathrooms have a working toilet, wash basin, and bathtub/shower. Linens & Hygiene Supplies: The required linen/supplies, including pillowcases, mattress paddings, sheets, fitted sheets, blankets, comforters, bedspreads, bath towels, hand towels, and washcloths, along with an adequate supply of linens, are stored in the hallway linen closets. Personal hygiene supplies for residents, including feminine napkins, soap, toothpaste, toothbrushes, toilet paper, hair brushes, and combs, are kept in the laundry room. See continued LIC809-C page 2

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Pamela Bunker
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: TRANQUIL MEADOWS HOME INC.	FACILITY NUMBER: 198320548
	VISIT DATE: 05/14/2025

NARRATIVE

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Continued LIC809-C page #2

Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers are posted and readily available for review in the laundry room on the wall bulletin board. The facility has a landline telephone located in the office. One (1) fully charged fire extinguisher is located in the kitchen. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils will be stored in a locked drawer located in the kitchen. Smoke/Carbon Monoxide Detectors: There are hardwire battery backup smoke alarms and carbon monoxide detectors located in the living room, hallway, dining room, kitchen, bedrooms, and laundry room, which are operational. Appliances: Refrigerator, stove/oven, microwave, Keurig coffee maker, and washer/dryer are installed, and all are in working condition. There is central air and heat throughout the facility. The hot water heater is located outside, at the back of the house, on the right side. Toxins: Cleaning supplies and toxins will be stored locked in a separate cabinet located in the laundry room, only accessible to staff. Water Temperature: The hot water temperature in the bathrooms was tested at 106 degrees Fahrenheit, within the normal limits (105-120F degrees Fahrenheit). Medication, First-Aid Kit & Manual: Centrally stored medications will be secured in a locked cabinet in the kitchen. There are sufficient bandages, tweezers, thermometers, scissors, and first aid kits with a manual. Staff & Clients Files: All staff and resident records will be kept confidential and securely stored in a locked cabinet in the laundry room. The applicant has submitted a secure bond and is responsible for managing residents' cash resources. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was approved on December 12, 2024. The facility yard is free of debris and hazards.

See continued LIC809-C page 3

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Pamela Bunker
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: TRANQUIL MEADOWS HOME INC.	FACILITY NUMBER: 198320548
	VISIT DATE: 05/14/2025

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Continued LIC809-C page #3

Component III Orientation:

Component III was completed with the Applicant Adeleke Bosoro during the Pre-Licensing visit. Information was provided on how to operate the facility in substantial compliance with regulations. When asked about her understanding of Title 22 regulations, the applicant affirmed her comprehension.

LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. Should the applicant have any questions regarding the status of the application, he has been instructed to contact the CAU analyst assigned to her application.

An exit interview was conducted, and a copy of this Facility Evaluation Report was provided to the applicant, Adeleke Bosoro.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Pamela Bunker
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC809 (FAS) - (06/04)

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