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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602215
Report Date: 04/11/2023
Date Signed: 04/11/2023 01:14:24 PM

Document Has Been Signed on 04/11/2023 01:14 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 6FACILITY NUMBER:
198602215
ADMINISTRATOR:EBENEZER AKINOLAFACILITY TYPE:
735
ADDRESS:52 RISING HILL RDTELEPHONE:
(909) 461-3879
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 4CENSUS: 3DATE:
04/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Teresa Cardenas /S-1, Ebony Allen /House Manager/S-2 and Ebenezer Akinola/Administrator TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA was allowed entry by Teresa Cardenas /S-1. LPA explained the purpose of today's visit. Ebony Allen /House Manager/S-2 arrived at approximately 9:15 A.M.. Ebenezer Akinola (Facility Administrator) arrived at approximately 9:45 A.M.

The facility is licensed for (4) ambulatory clients ages 18 through 59. The fire clearance is approved for (4) ambulatory clients. All clients residing at this home receive case management services provided by San Gabriel Pomona Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today 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 often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements.

Operational Requirements: The fire clearance is approved for (4) ambulatory clients. Last Fire Drill and Earthquake Drill were conducted on 02/04/2023. Staff are adhering to operational requirements.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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 3
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 6
FACILITY NUMBER: 198602215
VISIT DATE: 04/11/2023
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Physical Plant & Environment Safety: This facility consists of (4) private bedrooms, (2) bathrooms (one bathroom is located inside bedroom #4), living room, kitchen, dining room, den and an attached garage. The laundry unit is set-up inside the garage. Smoke alarms were tested and operable. Fire extinguisher appeared to be full and located in the kitchen. Carbon monoxide (located in the hallway) tested and operable. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Hot water supply measured 108.0* in the kitchen, 114.0* in the hallway bathroom and 115.6* in the bathroom inside bedroom #4.

Staffing: There is sufficient staffing at the facility. Administrator Certificate for Ebenezer Akinola expired on 10/22/2022. However, per Mr. Akinola, the renewal documents were submitted to CDSS in August 2022 and the CDSS database shows it continues to be on “pending status”. LPA obtained a copy of all the submitted documents. HIV Training Certificate is dated 04/29/2021. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator and S-1 through S-2. Staff have sufficient on-going training. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting, Client Rights and Zero Tolerance.

Client Rights-Information: Client personal rights are posted and included in client files. Internet services are provided and paid for by the facility. Per Administrator, clients have their own cell phone and/or tablet.

Client Records-Incident Reports: LPA reviewed Client files for C-1 through C-3. Client files are maintained at the facility. Admission Agreement, Functional Capability Assessment, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
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 6
FACILITY NUMBER: 198602215
VISIT DATE: 04/11/2023
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Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. An additional refrigerator and freezer with food observed inside the garage. The food is properly stored in the refrigerator (clean and well-maintained). Per Administrator, there are no clients on special diets. Pesticides and cleaning supplies are kept away from the food preparation areas (locked inside the garage). Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services The medications are centrally stored and in their original containers/bubbled packed and stored inside the medication cabinet located inside the garage. LPA reviewed medication for C-1 through C-3 The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Incidental Medical Services: Per Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.

Disaster Preparedness: The facility has an emergency disaster plan.

No deficiencies noted. Exit interview, appeals rights and a copy of this report was provided to Ebenezer Akinola.

Note: LPA experienced technical difficulties during this visit.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
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