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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603547
Report Date: 07/07/2023
Date Signed: 07/07/2023 03:17:40 PM

Document Has Been Signed on 07/07/2023 03:17 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
GREATER LA AC/SC, 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:
(562) 788-7639
CITY:PARAMOUNTSTATE: CAZIP CODE:
90723
CAPACITY: 6CENSUS: 6DATE:
07/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Omobola Adeleke - AdministratorTIME COMPLETED:
03:32 PM
NARRATIVE
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Omobola Adeleke (Administrator) and explained the reason for the visit.The facility is licensed to serve 5 ambulatory and 1 non-ambulatory clients in the age range 18 through 59, and non-ambulatory client shall be in bedroom #4. The facility is operating within the scope of its license.

A tour of the single-story facility included the living room, kitchen, dining area, 1 staff bedroom, 4 client bedrooms, 2 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. Chemical and cleaning solutions 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. Clean towels and extra clean linen were observed the hallway cabinets. Dining and living room have sufficient lighting and sitting area. Medications are centrally stored in a locked cabinet located in the dining area. Client and staff files will be kept locked in a dining area cabinet. All bedrooms have all required furniture, lighting, and bedding. All bathrooms were observed with shower mats. The water temperature was tested in both bathrooms and measured at 117.1 degrees F and 105.4 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in the kitchen and it is fully charged. Smoke detectors were observed throughout the facility and in each room and were operable during the visit. There is a carbon monoxide in the living room and was operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.

LPA reviewed medication for 5 clients and observed that medications are documented properly and given as prescribed. One of the clients is currently with the husband and took the medication with them. LPA reviewed files for all 6 clients and 5 staff files. (Continued to LIC 809-C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
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 07/07/2023 03:17 PM - It Cannot Be Edited


Created By: Luis Mora On 07/07/2023 at 01:33 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: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 5 staff files which poses/posed a potential health, safety or personal rights risk to persons in care. There was no personnel records for Staff 1 - Staff 5.
POC Due Date: 07/21/2023
Plan of Correction
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Facility is to ensure that Title 22 Section 80066 regulations are met at all times. Additionally, facility will submit copies of the personnel records by 07/21/2023.
Type B
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 out of 5 staff files which poses/posed a potential health, safety or personal rights risk to persons in care. There was no training documentation for Staff 1 - Staff 6.
POC Due Date: 07/21/2023
Plan of Correction
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Facility is to ensure that Title 22 Section 80065 regulations are met at all times. Additionally, facility will submit copies of the training by 07/21/2023.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 07/07/2023 03:17 PM - It Cannot Be Edited


Created By: Luis Mora On 07/07/2023 at 01:33 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: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(8)(B)
Personal Rights
(B) A written order from the client's physician indicating the need for the postural support shall be maintained in the client's record. The licensing agency shall be authorized to require additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 resident files which poses/posed a potential health, safety or personal rights risk to persons in care. Client 2 has a half bed rail, but no doctor's order for the bed rail.
POC Due Date: 07/21/2023
Plan of Correction
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Facility is to ensure that Title 22 Section 80072 regulations are met at all times. Additionally, facility will submit a copy of the doctor's order by 07/21/2023.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 6 out of 6 resident files which poses/posed a potential health, safety or personal rights risk to persons in care. The admission agreement for all 6 residents were not fully completed.
POC Due Date: 07/21/2023
Plan of Correction
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Facility is to ensure that Title 22 Section 80068 regulations are met at all times. Additionally, facility will submit copies of the completed admission agreements by 07/21/2023.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/07/2023 03:17 PM - It Cannot Be Edited


Created By: Luis Mora On 07/07/2023 at 01:33 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: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 6 out of 6 resident files which poses/posed a potential health, safety or personal rights risk to persons in care. All 6 residents did not have a Needs and Service Plan in their file.
POC Due Date: 07/21/2023
Plan of Correction
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Facility is to ensure that Title 22 Section 85068.2 regulations are met at all times. Additionally, facility will submit copies of the Needs and Service Plan by 07/21/2023.
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 resident files which poses/posed a potential health, safety or personal rights risk to persons in care. Client 2 did not have a physician report in their file.
POC Due Date: 07/21/2023
Plan of Correction
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Facility is to ensure that Title 22 Section 80069 regulations are met at all times. Additionally, facility will submit a copy of the physician report by 07/21/2023.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


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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: TABITHA CARE CORPORATION
FACILITY NUMBER: 198603547
VISIT DATE: 07/07/2023
NARRATIVE
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LPA observed administrator certificate for Omobola Adeleke - 6028359735 with an expiration date of 10/16/2023. LPA interviewed 2 staff and 2 clients.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit (Refer to LIC 809-D). Exit interview held and a copy of the report and appeal rights were provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 07/07/2023 03:17 PM - It Cannot Be Edited


Created By: Luis Mora On 07/07/2023 at 01:52 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: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069.2(a)
In order to determine whether the facility's program meets a client's services needs, the licensee of an ARF shall assess the client's need for personal assistance and care by determining his/her functional capabilities. The assessment shall be in writing, shall be used in developing the Needs and Service Plan, and shall include, but not be limited to the following activities:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 6 out of 6 resident files which poses/posed a potential health, safety or personal rights risk to persons in care. All 6 residents did not have a functional capabilities in their file.
POC Due Date: 07/21/2023
Plan of Correction
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Facility is to ensure that Title 22 Section 80069.2 regulations are met at all times. Additionally, facility will submit copies of the Functional Capabilities by 07/21/2023.
Type B
Section Cited
CCR
85068.1(b)
(b) No client may be admitted prior to a determination of the facility's ability to meet the needs of the client, which must include an appraisal of his/her individual service needs as specified in Sections 80068.2 and 85068.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 6 resident files which poses/posed a potential health, safety or personal rights risk to persons in care. Client 2, Client 4, Client 5, and Client 6 did not have or have an incomplete Preplacement Appraisal in their file.
POC Due Date: 07/21/2023
Plan of Correction
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Facility is to ensure that Title 22 Section 80069.2 regulations are met at all times. Additionally, facility will submit copies of the Preplacement Appraisal by 07/21/2023.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
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