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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603443
Report Date: 02/27/2025
Date Signed: 02/27/2025 10:35:02 AM

Document Has Been Signed on 02/27/2025 10:35 AM - 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:DHASA CAREFACILITY NUMBER:
198603443
ADMINISTRATOR/
DIRECTOR:		DEBELA-SLEDGE, HURUBEFACILITY TYPE:
735
ADDRESS:2181 LARCHMONT STTELEPHONE:
(773) 718-0819
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 3DATE:
02/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Emmanuel Ezeani (S-1) and Hurube SledgeTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA was allowed entry to the home by Emmanuel Ezeani (S-1). LPA discussed the purpose of today’s visit. Hurube Sledge (Administrator) arrived at approximately 10:20 A.M..

This is a single-story home which consists of (4) bedrooms, (2) bathrooms, living room, kitchen, dining room, activity room and an attached garage (laundry unit is set-up inside the garage). 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 (CARE) tools for the visit today and observed the following:

Infection Control: Facility has an Infection Control plan in place. PPE supplies were observed stored inside a kitchen cabinet.

Operational Requirements: Staff are adhering to operational requirements.

Physical Plant & Environment Safety: Smoke alarms and carbon monoxide detector tested and operable. Fire extinguisher was last serviced on 01/28/25 (located in the kitchen). Last fire drill was conducted on 11/10/24. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Hot water temperature measured at 109.0*.

Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2025
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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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: DHASA CARE
FACILITY NUMBER: 198603443
VISIT DATE: 02/27/2025
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Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: LPA reviewed staff files for the Administrator and Staff #1 (S-1) through Staff #4 (S-4). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis.

Client Rights-Information: Client rights are posted and were also observed in client files.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) through Client #3 (C-3). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Functional Capabilities Assessment, Consent For Medical Treatment, House Rules, Individual Program Plan, and Client Rights were observed.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. There is an additional freezer with food inside the garage. Additional non-perishable food and water were also observed to be inside the garage. Cleaning supplies are kept away from the food preparation areas. The 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 locked inside a kitchen cabinet. Medications are administered as prescribed by the Physician.

Incidental Medical Services: Per S-1, there are (0) clients with a restrictive health plan, (0) client utilizing postural supports and (0) clients with prohibited health conditions.

Disaster Preparedness: The facility has an Emergency Disaster Plan in place and observed to be posted.

Exit interview, appeals rights and a copy of this report was provided to Hurube Sledge (Administrator).
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC809 (FAS) - (06/04)
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