198601856-5-28-2024-28-AS-KRAZ-D5Q34H-20240528175511

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601856
Report Date: 05/28/2024
Date Signed: 05/28/2024 05:55:58 PM

Document Has Been Signed on 05/28/2024 05:55 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	RHEMA CARE GROUP LLC II		FACILITY NUMBER:	198601856
ADMINISTRATOR/ DIRECTOR:	KALU NWAKA		FACILITY TYPE:	735
ADDRESS:	755 WALNUTHAVEN DRIVE		TELEPHONE:	(818) 824-0340
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY: 4		CENSUS: 4	DATE:	05/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:39 PM
MET WITH:	Administrator Oghenetega Ugbeyide		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Kimberly Ramirez conducted an unannounced Annual Inspection visit on 05/28/2024. LPA Ramirez were met by Direct Support Staff (DSP) Chukwuka Mokogwu and explained the purpose of the visit. Administrator Oghenetega Ugbeyide arrived shortly after to assist with tour. This facility is licensed as a Adult Residential Facility and is serviced by San Gabriel/Pomona Regional Center. The facility is licensed to serve FOUR (4) developmentally disabled clients ages 18 and above; of which all must be ambulatory.

LPA OBSERVATIONS: The facility is a single-story home that contains four (4) bedrooms, two (2) bathrooms, living room, kitchen, dining room, laundry room, backyard, and garage.

Front Yard: LPA Ramirez observed front yard to be free of hazards.

Kitchen: LPA Ramirez observed appliances to be clean and in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located kitchen cabinet, to be inaccessible to clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants to be inaccessible to clients in care.

Dining Room/Living room: Dining room was observed to contain one table with several chairs. LPA Ramirez observed a fully charged fire extinguisher nearby.

Linen Closet/Supply Closet: Observed to contain plenty linens, towels, and hygiene products.

Client Rooms 1 - 4: All clients bedrooms are private. LPA Ramirez observed all client bedrooms to contain the required linens, furnishings, and lighting.

SEE 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

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 05/28/2024 05:55 PM - It Cannot Be Edited

Created By: Kimberly Ramirez On 05/28/2024 at 04:27 PM

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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RHEMA CARE GROUP LLC II	FACILITY NUMBER: 198601856
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, blackish and brown spots throughout various corners and upper ceiling of the bathroom#1 walls, the licensee did not comply with the section cited above in 4 out of 4 clients, and/or staff and visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/11/2024
	Plan of Correction
1 2 3 4	Licensee will clean walls. LPA will return to inspect.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Tony Vasallo

LICENSING EVALUATOR NAME:

Kimberly Ramirez

LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: RHEMA CARE GROUP LLC II	FACILITY NUMBER: 198601856
	VISIT DATE: 05/28/2024

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Bathroom 1-2: Water temperature in bathrooms was measured to be within 105-120 degrees F. LPA Ramirez observed blackish and brown spots throughout various corners of the bathroom#1 walls. LPA Ramirez will issue Type B deficiency.

Backyard: No large bodies of water were observed. LPA Ramirez observed various discarded items in backyard walkway. LPA Ramirez will issue Technical Violation.

Emergency Drills: Last

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit. Fully charged fire extinguishers were observed throughout the facility.

Personnel Records: Personnel records are maintained at the facility. LPA Ramirez reviewed three (3) personnel records. No deficiencies were observed. Administrator's Certificate for Oghenetega Ugbeyide was observed with an expirationdate of 07/23/2024.

Client Records: Client files are maintained at the facility. LPA Ramirez reviewed four (4) client records. No deficiency was observed. Admissions Agreement, Medical Assessment, Consent Forms, Appraisal and Needs and Services plan, I.D and Emergency Information, TB Test, Centrally Stored Medication Record, and Personal Rights Form were observed.

Infection Control Plan: LPA Ramirez observed updated Infection Control Plan and Emergency Disaster Plan.

One (1) deficiency was observed and cited today. Exit interview was conducted. A copy of this report, 809-D, LIC 9102 and appeals rights was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

LIC809 (FAS) - (06/04)

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