198603369-9-18-2025-28-AS-SVAD-DLMS24-20250918132852

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603369
Report Date: 09/18/2025
Date Signed: 09/18/2025 02:08:13 PM

Document Has Been Signed on 09/18/2025 02:08 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 INC		FACILITY NUMBER:	198603369
ADMINISTRATOR/ DIRECTOR:	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:	09/18/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:01 AM
MET WITH:	Adedolapo Olusoji-Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:45 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)s E Mallett and S Vaid conducted the annual inspection. LPA arrived and met with Staff, Nathaniel Olatunbosun, who allowed entry to the facility. The purpose of the visit was explained. Administrator, Adedolapo Olusoji, arrived later to assist with the visit. Clients are vendorized through San Gabriel Pomona Regional Center. LPA utilized 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. C2 screen door observed to be broken. C2 room walls are soiled. Cited two (2). Operational Requirements: 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 clean. 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. C2 medication was marked as administered for PM, medication has not yet been administered. Cited one (1). Staffing: There is sufficient staffing at the facility. The administrator's (Adedolapo Olusoji) certificate expires on 12/22/2026. The HIV and TB Training certificate was completed. Staff employed are fingerprinted and associated with the facility. Continued on 809C...........

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 09/18/2025 02:08 PM - It Cannot Be Edited

Created By: Sanjay Vaid On 09/18/2025 at 12:41 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: 09/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(b)

This requirement is not met as evidenced by:C2 patio screen was observed broken.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) , the licensee did not comply with the section cited above in C2 room which presents/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2025
	Plan of Correction
1 2 3 4	Picture of repair.

Type B

Section Cited

CCR

85095.5(B)

This requirement is not met:Walls and window coverings in clients care areas shall be dusted and cleaned on regular basis.To ensure safe and sanitary when visibily contaminatede or soiled. Visually soiled wall. in C2's room.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) , the licensee did not comply with the section cited above in one out of four rooms. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2025
	Plan of Correction
1 2 3 4	Clean wall and sent picture.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:

	Sanjay Vaid
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 09/18/2025 02:08 PM - It Cannot Be Edited

Created By: Sanjay Vaid On 09/18/2025 at 12:51 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: 09/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85075(b)

This requirement is not met as evidenced by: Staff recording medication before administering.In 0ne of four clients files reviewed. LPA observed staff recorded medication was dispensed in the before it was ever dispensed.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in one of four clients files. Medication was recorded before being administer which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2025
	Plan of Correction
1 2 3 4	Lisensee to provide in-service training and send to LPA by due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:

	Sanjay Vaid
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

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: 09/18/2025

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 an 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.

Three (3) Deficiencies are being made today. An exit interview was held. A copy of this report along with appeal rights were provided to the administrator.

Due to printer issues report 9099,9099c, 9099D and 9099D along with appeals rights will be mailed to the licensee.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

LIC809 (FAS) - (06/04)

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