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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603547
Report Date: 09/26/2024
Date Signed: 09/26/2024 01:43:07 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2024 and conducted by Evaluator Tyler Reyes
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240919155110
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: 9DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Licensee/Administrator OmobolaTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Facility operating over the approved capacity.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Tyler Reyes conducted an initial complaint visit to address the allegation listed above. LPA met with Omobola Licensee/Administrator for the facility, and explained the purpose of the visit.

The investigation consisted of the following: During the visit, LPAs interviewed Client #1 - 7 (C1 - C7), Resident #1 (R1), and Staff #1 (S1 and S2) . LPA Reyes attempted to interview C8 however C8 was unavaliable to be interviewed. LPAs requested copies of the client roster, staff roster, physican report, face sheet, and facility sketch.

The investigation revealed the following: In regards to the allegation that Facility operating over the approved capacity, it is alleged that the facility is operating over capicity with (9) clients despite being licensed for (6) clients.

--Conintued LIC 9099-C--
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Tyler Reyes
LICENSING PROGRAM ANALYST 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20240919155110
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CORPORATION
FACILITY NUMBER: 198603547
VISIT DATE: 09/26/2024
NARRATIVE
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(2) of (2) staff confirmed the allegation. Staff indicated that they are currently caring for (8) clients and (1) resident despite being licensed for (5) Ambulatory and (1) Non ambulatory clients 18-59 years old. (7) of (8) clients confirmed the allegation. (1) of (1) resident confirm the allegation. Client and resident stated they have been residing at the facility. During the facility walk through conducted with the Licensee, LPA observed a total of (9) beds, with (8) beds occupied by clients and (1) bed occupied by a resident. LPA confirmed the presence of all (8) clients and (1) resident during the visit, verifying that each bed was assigned and in use. During record review LPA reviewed LIC 9020 Register of Facility Client/Residents of (9) individuals residing at the facility provided by Licensee.


Therefore, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Immediate Civil Penalties will also be issued today, in the amount of $500.00 due to Facility operating over the approved capacity of their Facility License.

Exit interviewed conducted and a copy of this report was provided with appeal rights.


NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Tyler Reyes
LICENSING PROGRAM ANALYST 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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240919155110
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 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 A
09/27/2024
Section Cited
CCR
80010(a)
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80010 Limitations on Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation
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Licensee will notify the local fire department of the additional clients and assist with client relocation. Licensee will submit proof of contact with fire department and details of the clients' relocation will be provided to LPA. Licnesee agrees to abiding to capciity limit.
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Based on observations LPA observed a total of (9) beds, with (8) beds occupied by clients and (1) bed occupied by a resident. LPA confirmed the presence of all (8) clients and (1) resident during the visit, verifying that each bed was assigned and in use and interviews with Staff #1 (S1 and S2) the facility is operating over capacity. This poses an immediate health, safety or personal rights risk to persons 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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Tyler Reyes
LICENSING PROGRAM ANALYST 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3