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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603369
Report Date: 08/23/2024
Date Signed: 08/23/2024 02:42:52 PM

Document Has Been Signed on 08/23/2024 02:42 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DAZION INCFACILITY NUMBER:
198603369
ADMINISTRATOR/
DIRECTOR:		ADEDOLAPO OLUSOJIFACILITY TYPE:
735
ADDRESS:734 GLENEAGLES AVENUETELEPHONE:
(909) 233-4528
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 4CENSUS: 4DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:37 PM
MET WITH:Administrator Olusoji AdedolapoTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA arrived at approximately 11:05 AM and attempted to get in contact with Administrator Olusoji Adedolapo and was able to reach him at 11:29 AM. Administrator stated he would be on his way and arrived at facility at 12:37 PM. Tour of the facility started at 12:37 PM.

Facility is licensed to serve four (4) ambulatory developmentally disabled adults, ages 18-59. This single-story home contains Four (4) bedrooms, one (1) office, two (2) bathrooms, a living room, kitchen, dining area, laundry area, enclosed patio/activity area, backyard, and garage.

LPA toured the facility and observed the following: Two (2) out of four (4) client bedrooms has the required furniture and bedding. Bedroom #2 and #3 missing chairs TV given. There is extra clean linen and towels in hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the hallway and is properly operating. The facility has one (1) fully charged fire extinguisher which is kept in kitchen. Cleaning supplies and toxic substances where accessible to clients during visit LPA observed cleaning supplies under sink in bathroom #1. LPA observed cleaning supplies to be locked in storage in garage as well as within other locked cupboards in laundry room. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There is an extra freezer and refrigerator in garage with more food. 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. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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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Document Has Been Signed on 08/23/2024 02:42 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/23/2024 at 02:27 PM
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: 08/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 LPA obseved cleaning supplies in bathroom #1 during visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2024
Plan of Correction
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Administrator removed cleaning supplies during visit and will conduct training with staff and email a training log to LPA.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 C1 had insulin in refrigerator not in locked box which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2024
Plan of Correction
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Administrator will buy lock box and email LPA receipts as proof.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DAZION INC
FACILITY NUMBER: 198603369
VISIT DATE: 08/23/2024
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Four (4) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Four (4) client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP)report. Last fire/earthquake drill was conducted in June of 2024. Infectious control plan was reviewed. Four (4) client medications were reviewed. Medications are centrally stored and locked MAR log is used. LPA observed C1 insulin not in locked box in refrigerator deficiency cited.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Administrator Olusoji.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
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