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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603547
Report Date: 09/26/2024
Date Signed: 09/26/2024 01:45:41 PM

Document Has Been Signed on 09/26/2024 01:45 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:TABITHA CARE CORPORATIONFACILITY NUMBER:
198603547
ADMINISTRATOR/
DIRECTOR:		ADELEKE, OMOBOLAFACILITY TYPE:
735
ADDRESS:14412 COKE AVENUETELEPHONE:
(562) 788-7639
CITY:PARAMOUNTSTATE: CAZIP CODE:
90723
CAPACITY: 6CENSUS: 9DATE:
09/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:49 PM
MET WITH:Licensee/Administrator OmobolaTIME VISIT/
INSPECTION COMPLETED:
01:47 PM
NARRATIVE
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Licensing Program Analyst (LPA) Reyes generated this Case Management - Deficiencies report in conjunction with complaint control 28-AS-20240919155110 pertaining to observation and record review of the facility sketch. Based on the facility sketch submitted by the facility to the Monterey Park Regional Office(RO) "Living Room 2" has been converted into bedroom #5 without submitting the necessary documents. Bedroom #5 is a converted bedroom for Client #1 (C1).


Based on observation, a citation is being issued. See LIC 809D.

An exit interview was conducted and a copy of the report and appeal rights were issued.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/26/2024 01:45 PM - It Cannot Be Edited


Created By: Tyler Reyes On 09/26/2024 at 01:18 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: TABITHA CARE CORPORATION
FACILITY NUMBER: 198603547

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/03/2024
Section Cited
CCR
80022(b)(7)

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80022 Plan of Operation
(b) The plan and related materials shall contain the following: (7) A sketch of the building(s) to be occupied, including a floor plan which describes the capacities of the buildings for the uses intended, room dimensions, and a designation of the rooms to be used for nonambulatory clients, if any.
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Facility will provide evidence that the required permits were obtained and that the room was cleared by the fire department for client use or relocate the clients to a room that was approved for client use.
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Based on observations and record review of the facility sktech LPA Reyes observed facility sketch submitted by the facility to the Monterey Park Regional Office(RO) "Living Room 2" has been converted into bedroom #5 without submitting the necessary documents. This poses a potential Health, Safety, and/or Personal Rights risk to the clients in care.
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Tyler Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
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