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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602214
Report Date: 05/24/2022
Date Signed: 05/24/2022 10:38:40 AM

Document Has Been Signed on 05/24/2022 10:38 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CENTER FOR BEHAVIORAL CHANGE 7FACILITY NUMBER:
198602214
ADMINISTRATOR:EBENEZER AKINOLAFACILITY TYPE:
735
ADDRESS:772 COBRE CTTELEPHONE:
(909) 629-1715
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 5CENSUS: 4DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Ebenezer Akinola, AdministratorTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with staff member, Adesola Odetunde and explained the reason for the visit. Administrator, Ebenezer Akinola arrived a short time later. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed clients' medications and records and observed the food supply, The facility cares for adults with developmental disabilities and is vendorized by San Gabriel/Pomona Regional Center as a Level 4N facility.

All client bedrooms were toured. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. Both client bathrooms were toured and the hot water was 108.2 degrees which is within the required 105 - 120 degrees. There were no toxic chemicals accessible to clients. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and are operating properly. The common areas include the living room and dining area. These areas are clean and have the required furniture. There is a screening station at the entrance of the home which has PPEs and a thermometer to screen visitors. Staff document client temperatures daily and require visitors to sign in. Facility currently has at least a 30-day supply of PPEs. There are no cameras inside or outside the facility.

Client files were reviewed to confirm emergency contacts are updated. Staff files were reviewed to confirm health screenings, training and fingerprint clearances. All clients' medications were reviewed. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held. A copy of the report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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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