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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603578
Report Date: 12/19/2023
Date Signed: 12/19/2023 03:29:00 PM

Document Has Been Signed on 12/19/2023 03:29 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:RHEMA CARE GROUP ALFORDFACILITY NUMBER:
198603578
ADMINISTRATOR:NWAKA, ANGELAFACILITY TYPE:
735
ADDRESS:1034 E. ALFORD STREETTELEPHONE:
(626) 324-3134
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 4CENSUS: 4DATE:
12/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:46 AM
MET WITH:Gideon Imeh - House Manager TIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Gideon Imeh and explained the reason for the visit.

The facility is licensed to serve as an Adult Residential Facility for 4 ambulatory clients in the age range of 18 through 59. It is located in a residential and it is a one story family home, which includes 4 client bedrooms, 2 bathrooms, living room, kitchen, attached garage, front yard and back yard.

LPA toured the facility with Gideon Imeh and observed the following:
The facility is in good repair in the outside. Kitchen was observed clean, sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. Refrigerator and freezer do not have a thermometer and LPA was unable to tell the temperature. Dining room and living room have sufficient sitting area. Living room was observed with a cover fireplace. Four client bedrooms were observed to have sufficient lighting, the required furniture and bedding supplies. Room #1 was observed with a hole of about a baseball in the entry wall, Room #3's door was observed with a hole the size of about 6in by 6in, door panel for storage was observed bend and dislodge from the door frame, bathroom #2 was observed with toilet's water tank lid missing, and a hole on the wall next to the door the size of about a baseball. Room #4 does not have a door. Outdoor area does not have a shaded sitting area. No large bodies of water were observed.
Fire extinguisher was observed in the kitchen. Smoke/carbon monoxide detectors were tested and are in working condition.
Medication was reviewed for 4 clients, P&I money was reviewed for 2 clients. Files were reviewed for 3 clients, client #1-2(C1-C2) did not have a copy of admission agreement, C1-C3 did not have a copy of physician's report, and C2-C3 did not have a TB test on file, and client #4(C4)'s file was not available for review. Files were reviewed for 3 staff and files for staff #3-4 (S3-S4) were not available for review. Last fire drill was conducted on 9/29/23. (CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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 10
Document Has Been Signed on 12/19/2023 03:29 PM - It Cannot Be Edited


Created By: Mary G Flores On 12/19/2023 at 02:29 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: RHEMA CARE GROUP ALFORD
FACILITY NUMBER: 198603578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80022(e)(4)
Plan of Operation
(e) If the licensee intends to admit or care for one or more clients who rely upon others to perform all activities of daily living, the plan of operation must also include a statement that demonstrates the licensee's ability to care for these clients. The evidence of ability may include but not be limited to: (4) Documentation of training the licensee and/or staff have completed specific to the needs of these clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in training was not available for review for administrator, S3,S4, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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Administrator will provide copies of training for administrator, S3, and S4 to the department by POC due date 1/2/24.
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the facility does not have a outdoor furniture with shade which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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Administrator will purchase a furniture and provide shade and will submit pictures to the department by POC due date 1/2/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 12/19/2023 03:29 PM - It Cannot Be Edited


Created By: Mary G Flores On 12/19/2023 at 02:29 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: RHEMA CARE GROUP ALFORD
FACILITY NUMBER: 198603578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in administrator's training was not available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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Administrator will provide a copy of HIV/TB training to the department by POC due date 1/2/24.
Type B
Section Cited
CCR
80068(g)
Admission Agreements
(g) The licensee shall retain in the client's file the original of the initial admission agreement and all subsequent modifications.

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 C1 and C2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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Administrator will obtain a copy of admission agreement and submit a copy to the department by POC due date 1/2/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 12/19/2023 03:29 PM - It Cannot Be Edited


Created By: Mary G Flores On 12/19/2023 at 02:29 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: RHEMA CARE GROUP ALFORD
FACILITY NUMBER: 198603578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)
Client Medical Assessments
(c) The medical assessment shall include the following:

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 C1-C3 did not have a copy of physician's report/medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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Administrator will obtain a copy of physician's report that meets the department's criteria and will submit a copy to the department by POC due date 1/2/24.
Type B
Section Cited
CCR
80070(d)
Client Records
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observantion and record review, the licensee did not comply with the section cited above in file for C4 was not available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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Administrator will provide a copy of documents pertaining to C4 to the department by POC due date 1/2/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 12/19/2023 03:29 PM - It Cannot Be Edited


Created By: Mary G Flores On 12/19/2023 at 02:45 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: RHEMA CARE GROUP ALFORD
FACILITY NUMBER: 198603578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
80066 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 observation and record review, the licensee did not comply with the section cited above in files for S3-S4 were not available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2024
Plan of Correction
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Administrator will provide a copy of S3-S4 files to the department by POC due date 1/2/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


LIC809 (FAS) - (06/04)
Page: 9 of 10
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: RHEMA CARE GROUP ALFORD
FACILITY NUMBER: 198603578
VISIT DATE: 12/19/2023
NARRATIVE
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Emergency disaster plan was reviewed and infection control plan was not available for review. Administrator certificate was observed for Kalu Nwaka #6026578735 exp date: 10/4/24 documents were submitted to the department for a change of administrator on 11/15/23.

Deficiencies are being cited today per Title 22 Regulations.

Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights will be email to administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC809 (FAS) - (06/04)
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