198603369-9-12-2023-28-AS-CDCN-CVLV64-20230912160854

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603369
Report Date: 09/12/2023
Date Signed: 09/12/2023 04:09:26 PM

Document Has Been Signed on 09/12/2023 04:09 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:	DAZION INC		FACILITY NUMBER:	198603369
ADMINISTRATOR:	ADEDOLAPO OLUSOJI		FACILITY TYPE:	735
ADDRESS:	734 GLENEAGLES AVENUE		TELEPHONE:	(909) 233-4528
CITY:	POMONA	STATE: CA	ZIP CODE:	91768
CAPACITY: 4		CENSUS: 4	DATE:	09/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Kenneth Andiobi, Staff		TIME COMPLETED:	04:15 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. LPA arrived and met with Staff, Kenneth Andiobi, who allowed entry to the facility. The purpose of the visit was explained. Administrator, Adedolapo Olusoji, arrived later to assist with the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools to inspect the home. Infection Control: Staff are cleaning and disinfecting high touched surfaces daily. They are using appropriate hand hygiene and wearing gloves when necessary to assist clients. The facility has submitted the Infection Control Plan. Physical Plant & Environment Safety: The facility consists of 4 client bedrooms, staff office, 2 bathrooms, living room, kitchen, laundry area, and a garage. Knives and cleaning solutions are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Hot water was measured within the required range of 105 - 120 degrees F. The facility does not have a swimming pool. There is a carbon monoxide detector and smoke detectors observed. Operational Requirements: The fire clearance is approved for (4) ambulatory clients. Staff are adhering to operational requirements as there are 4 ambulatory clients residing at the home. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The foods are properly stored in the refrigerator. Plates, cups and utensils are kept cleaned. Health Related Services: The medications are centrally stored and locked in the file cabinet. LPA reviewed medications for all 4 clients and they are being administered as prescribed by the Physician and properly documented. Staffing: There is sufficient staffing at the facility. The administrator's (Adedolapo Olusoji) certificate expires on 12/22/24. The HIV and TB Training certificate was completed on 11/15/22. Staff employed are fingerprint cleared and associated to the facility.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

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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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: DAZION INC	FACILITY NUMBER: 198603369
	VISIT DATE: 09/12/2023

NARRATIVE

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Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed files for 4 Staff. Staff files have current First Aid/CPR certification, Health Screening and Tuberculosis Screening on file. Staff are receiving on-going training.
Client Rights-Information: There are no clients using postural supports. Clients are provided with internet access and devices for use.
Client Records-Incident Reports: LPA reviewed files for all 4 Clients. Client files are maintained at the facility. Each client file has the Admission Agreement, Medical assessment including TB test results, Weight Record, Consent Forms, Individual Program Plan/IPP, Client Rights, and Safeguarding forms for inventory and cash.
Incidental Medical Services: There are no clients with prohibited health conditions.
Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D) with relocation sites and shutoff valve locations. LPA requested to update the LIC610D to include emergency procedures.
Emergency Intervention: The staff do not utilize manual restraint but will use verbal redirection techniques to de-escalate a behavior.

No deficiencies are issued today. An exit interview was held. A copy of this report along with appeal rights were provided to the administrator.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC809 (FAS) - (06/04)

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