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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603547
Report Date: 07/09/2024
Date Signed: 07/09/2024 12:00:15 PM

Document Has Been Signed on 07/09/2024 12:00 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/
DIRECTOR:
ADELEKE, OMOBOLAFACILITY TYPE:
735
ADDRESS:14412 COKE AVENUETELEPHONE:
(562) 788-7639
CITY:PARAMOUNTSTATE: CAZIP CODE:
90723
CAPACITY: 6CENSUS: 6DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:57 AM
MET WITH:Omobola Adeleke (Administrator)TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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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 in a kitchen closet. 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 112.1 degrees F and 114.4 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 6 clients and observed that medications are documented properly and given as prescribed. LPA reviewed files for 6 clients and 5 staff files. LPA observed administrator certificate for Omobola Adeleke - 6028359735 with an expiration date of 10/16/2025.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. 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: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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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