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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603369
Report Date: 09/14/2021
Date Signed: 09/14/2021 12:37:30 PM

Document Has Been Signed on 09/14/2021 12:37 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DAZION INCFACILITY NUMBER:
198603369
ADMINISTRATOR:ADEDOLAPO OLUSOJIFACILITY TYPE:
735
ADDRESS:734 GLENEAGLES AVENUETELEPHONE:
(909) 233-4528
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 4CENSUS: 3DATE:
09/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Adedolapo OlusojiTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nicole Spencer conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA Spencer was greeted by administrator Adedolapo Olusoji and discussed the purpose of today's visit. This single-story home contains four (4) bedrooms, two (2) bathrooms, an office, a living room, kitchen, dining room, backyard, and attached garage.
The following was observed/inspected:
  • The facility had a universal entrance screening area including a sign-in sheet, thermometer, and hand sanitizer. A temperature check log for staff and residents was maintained daily.
  • COVID-19 signage was placed in several areas including entrance and common areas.
  • Facility did not maintain a 30-day supply of PPE including N-95, gowns, and face shields.
  • Staff wore face masks throughout their shift and furniture was spaced for physical distancing.
  • There was a sufficient supply of 2-day perishable foods and 7-day non-perishable foods.
  • Cleaning solutions and sharps were locked and inaccessible.
  • Water temperature was measured and were not within required 105-120 degrees F. Bathroom temperatures were measured at 129.3 and 127.5, and kitchen was measured at 129.7.
  • All resident rooms contained required furniture including bed, dresser, night stand, lamp and chair.
  • Medications were locked and centrally stored. However, medications were not given as prescribed due to missing medications.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • Indoor/outdoor passageways were free from obstruction.
  • The common bathroom was in disrepair due to toilet and shower not in working order.
  • A fire extinguisher was observed to be fully charged and recently serviced.
  • Client files were inspected and emergency contact information and health screenings were up to date for all clients. Staff files were inspected and contained the required health screenings, criminal record clearances, and trainings. Administrator certificate expires on 12/2022.
Pursuant to Title 22, deficiencies were cited on the attached 809D. An exit interview was conducted and a copy of this report and appeal rights were provided to the administrator
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
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 6
Document Has Been Signed on 09/14/2021 12:37 PM - It Cannot Be Edited


Created By: LaJean Nicole Spencer On 09/14/2021 at 11:51 AM
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: DAZION INC
FACILITY NUMBER: 198603369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 3 faucets which poses an immediate health, safety or personal rights risk to persons in care. Water temperature in bathrooms measured 129.3 and 127.5 degrees F and kitchen measured 129.7 degrees F.
POC Due Date: 09/15/2021
Plan of Correction
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The administrator stated that he will have a plumber fix the meter by 9/15/21. In addition, the administrator stated that he will log temperature of water twice a day for the next 7 days and send log to CCL following the 7 days.
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above for 2 out of 3 clients which poses an immediate health, safety or personal rights risk to persons in care. For client 2, DOC 100 mg was missing from the facility. Administrator stated that it was recently discontinued but did not provide discontinuation orders. For client 3, Trazadone 100 mg was not at the facility and MuPricolin Ointment 20% was not taken or marked on MAR.
POC Due Date: 09/15/2021
Plan of Correction
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The administrator stated that the medication Trazadone 100 mg would be arriving at the facility today and Mipricolin Ointment was recently re-ordered and arrived yesterday and will be given as prescribed. The administrator stated that he will provide discontinuation orders for DOC 100 mg to CCL by POC due date. The administrator will also provide medications training for staff and send training logs to CCL by POC due date.
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:Christine Yee
LICENSING EVALUATOR NAME:LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/14/2021 12:37 PM - It Cannot Be Edited


Created By: LaJean Nicole Spencer On 09/14/2021 at 11:52 AM
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: DAZION INC
FACILITY NUMBER: 198603369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021

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
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Based on observation, the licensee did not comply with the section cited above in 1 out of 2 bathrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2021
Plan of Correction
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The administrator stated that the common bathroom was in disrepair since yesterday and someone was coming out today to fix it. Administrator stated that he will send pictures of repaired toilet and shower to CCL by POC due date.
Type B
Section Cited
CCR
85087(a)(4)
Building and Grounds
(4) No client bedroom shall be used as a public or general passageway to another room, bath or toilet.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for 1 out of 3 clients which poses/posed a potential health, safety or personal rights risk to persons in care. Due to the common bathroom being in disrepair, 2 clients must enter through another client's bedroom to use the other toilet and shower.
POC Due Date: 09/15/2021
Plan of Correction
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The administrator stated that the common bathroom would be repaired so that clients do not have to use the private bathroom located inside another client's room. Administrator stated that he will send pictures of repaired toilet and shower to CCL by POC due date.
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:Christine Yee
LICENSING EVALUATOR NAME:LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021


LIC809 (FAS) - (06/04)
Page: 3 of 6