<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602214
Report Date: 05/04/2023
Date Signed: 05/04/2023 04:00:41 PM

Document Has Been Signed on 05/04/2023 04:00 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: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:
05/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Toyin Olotu, staffTIME COMPLETED:
04:05 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) Cynthia Chan conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA arrived unannounced and met with Staff, Toyin Olotu. The purpose of the visit was explained. Administrator, Ebenezer Akinola, arrived at 1:10pm to assist with the visit. The facility is licensed for (5) ambulatory clients, ages 18 - 59.

LPA toured the facility and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting at least once during each shift and more often for high touched surfaces. Facility has sufficient PPE supplies.
Physical Plant & Environment Safety: The one-story home has 4 bedrooms, 2 bathrooms, laundry room, living room with open kitchen, and an attached garage. Each client bedroom has the required furniture and bedding. The facility does not have a swimming pool or bodies of water on the premises. The smoke detectors are interconnected and operable. The carbon monoxide detector was also tested and operable. Knives, cleaning solutions, and disinfectants are locked inside a cabinet located in the garage. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F.
Operational Requirements: The facility is licensed for (5) ambulatory adults ages 18 - 59. There are currently 4 clients residing at the home and were placed by the San Gabriel/Pomona Regional Center.
Staffing: There is sufficient staffing at the facility, with at least 2 staff in each shift. Staff are fingerprint cleared and associated to the facility.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: CENTER FOR BEHAVIORAL CHANGE 7
FACILITY NUMBER: 198602214
VISIT DATE: 05/04/2023
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
26
27
28
29
30
31
32
Personnel Records-Training: Staff files are maintained at the facility. Administrator (Ebenezer Akinola) certificate expires on 10/22/2024. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. LPA reviewed (4) personnel files and the required documents are in their files. Clients Rights - Information: The clients are given internet access and are provided with reasonable level of personal privacy.
Client Records-Incident Reports: Resident files are maintained at the facility. LPA reviewed all (4) client files and they have the required documentation including current Individual Program Plan. There is one client with a restricted health condition and is documented on the individuals care plan.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. Freezers are maintained at a temperature of 0 degree F and the refrigerators at a maximum of 45 degrees F. Both are kept clean and food are properly stored.
Health-Related Services: The medications are centrally stored and locked in a cabinet by the kitchen. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all 4 clients and they are being administered as prescribed by the physician.
Incidental Medical & Dental: There are no clients who require health services or has a health condition that requires staff supervision.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Staff are provided training on the emergency procedures and know where the utility shutoff valves are located. The client roster is posted and the clients' face sheet have been updated.
Emergency Intervention: Staff have training on behavior intervention using ProAct. LPA reviewed 4 staff CPR/first aid the certificates have not expired. The staff will use manual restraint on a client as the last resort.

There are no deficiencies issued today. An exit interview was held. A copy of this report and appeal rights were given to the staff.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2