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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603547
Report Date: 05/17/2022
Date Signed: 05/17/2022 10:56:24 AM

Document Has Been Signed on 05/17/2022 10:56 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:TABITHA CARE CORPORATIONFACILITY NUMBER:
198603547
ADMINISTRATOR:ADELEKE, OMOBOLAFACILITY TYPE:
735
ADDRESS:14412 COKE AVENUETELEPHONE:
(626) 639-9186
CITY:PARAMOUNTSTATE: CAZIP CODE:
90723
CAPACITY: 4CENSUS: 0DATE:
05/17/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Omobola Adeleke - AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analysts (LPAs) Luis Mora, Ashley Calderon and Valeria Maldonado conducted an announced Pre-Licensing visit. LPA met with Administrator Omobola Adeleke and explained the reason for the visit. An application was submitted to Community Care Licensing Department (CCLD) for an Adult Residential Facility to serve 3 ambulatory and 1 non-ambulatory clients in the age range of 18 through 59.

A tour of the single-story facility included: living room, kitchen, dining area, 4 client bedrooms, 3 client bathrooms, attached garage, front yard, and backyard.

LPA Mora conducted the tour with Omobola Adeleke and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps are kept locked under the kitchen sink. The First Aid kit is kept locked in the medication cabinet. The First Aid kit was fully stocked with all required items including a current manual. Cleaning and chemical solutions are kept locked in a kitchen closet. Dining and living room have sufficient lighting and sitting area. Medications are centrally stored in a locked cabinet located in the dining area. All bedrooms have all required furniture, lighting, and bedding. There are clean linen and towels in a hallway cabinet. All bathrooms were observed with shower mats. Water temperature was tested at 115.2 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in the dining area, and it is fully charged. Smoke detectors combined with carbon monoxides were observed throughout the facility and in each room and were operable during the visit. Client and staff files will be kept locked in a kitchen closet. The front yard and backyard are clean, and there is a shaded sitting area in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction. No outstanding or pending items were observed by LPAs requiring additional pre-licensing visits. LPAs will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed pre-licensing facility evaluation visit conducted, which included the Component III Orientation. Exit interview conducted and a copy of this report was provided to the Administrator.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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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