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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603578
Report Date: 11/17/2025
Date Signed: 11/17/2025 02:16:14 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
11/14/2025 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251114123349
FACILITY NAME:RHEMA CARE GROUP ALFORDFACILITY NUMBER:
198603578
ADMINISTRATOR:NWAKA, KALUFACILITY TYPE:
735
ADDRESS:1034 E. ALFORD STREETTELEPHONE:
(626) 210-1447
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY:4CENSUS: 4DATE:
11/17/2025
UNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Omolola Oshodi - DSPTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are not following a resident's dietary plan.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Omolola Oshodi, DSP and explained the reason for the visit. Shortly after, Administrator, Henry Obi-Ijomah was called and discussed the purpose of the visit.

Investigation consisted of the following: LPA obtained a copy of the staff & client rosters, In service staff training and Client #1 (C1) files such as; Admission Agreement, Identification & Emergency
Information, Physician Report, Hospital discharge records (09/02/2025), PEG feeding care plan, Behavior plan, Restricted healthcare plan (9/14/2025) and Unusual Incident/Injury reports (SIRs Sep. 2025 - Nov. 2025). LPA interviewed Staff #2 (S2) - Staff #3 (S3) in person, Staff #1 (S1) and Service Coordinator (SC) San Gabriel Pomona Regional Center on the phone. LPA attempted to interview Client #1 (C1) - Client #2 (C2) but unsuccessful due to their cognitive abilities. *****CONTINUED ON LIC 9099-C*****
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025
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-20251114123349
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: RHEMA CARE GROUP ALFORD
FACILITY NUMBER: 198603578
VISIT DATE: 11/17/2025
NARRATIVE
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The investigation revealed the following:

Allegation: "Staff are not following a resident's dietary plan." It is alleged that C1 has a history of recurrent aspiration pneumonia and a G tube and should be on a pureed diet and have a choking care plan in place. However, despite C1's last release orders to be on a pureed food diet, C1 was given chopped food without an approval from C1's physician. Interviews conducted with staff and SC revealed that C1 was recently admitted in the facility on 09/14/2025. C1's restricted health care plan dated 09/14/2025 was reviewed and showed that C1 has a recurrent aspiration pneumonia with (2) hospitalization in the past 3 months. C1 was admitted to the hospital on 09/02/2025 for PEG-tube placement with discharge diet instruction for thin liquid and one-to-one feeding assistance with all oral intake. All (3) staff interviewed stated they have been giving chopped food to C1, because C1 had insisted, otherwise, C1 will throw a behavior. During the interviews, S1 told SC that a hospital nurse had verbally given permission for the chopped food, but in contradiction, S1 told LPA that the doctor from the hospital had verbally given permission for the chopped food. Additional documents reviewed showed that the training on PEG feeding care was given to staff on 09/14/2025. However, C1's behavior plan did not include any documented interventions. Furthermore, there was no medical documentation or doctor's confirmation instructing staff to provide C1 with solid or chopped food. Interview with SC revealed that the Regional Center is currently investigating this allegation and has not reached a conclusion. Documentation reviewed and interviews conducted corroborate this allegation.

Based on interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to the Omolola Oshodi, DSP along with the Appeals Rights. A copy of the report was also emailed to Henry Obi-Ijomah, Administrator.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20251114123349
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: RHEMA CARE GROUP ALFORD
FACILITY NUMBER: 198603578
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/25/2025
Section Cited
CCR
80076(a)(6)(A)
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80076 Food Services (a) In facilities providing meals to clients, the following shall apply: ( 6) Modified diets prescribed by a client's physician as a medical necessity shall be provided. (A) The licensee shall obtain and follow instructions from the physician or dietitian on the preparation of the modified diet.
This requirement is not met as evidenced by:
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Administrator shall ensure that restricted health diets prescribed by a client's physician as a medical necessity shall be provided at all times. Administrator shall conduct an in-service training to all staff to ensure full understanding of the importance of complying with Title 22 Regs Sec 80076.
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Based on observation, interviews, records review, the Administrator did not comply with the section cited above in which C1 who has a history of recurrent aspiration pneumonia was given chopped food without physician's orders, despite discharge orders to be on a pureed food diet which poses an immediate health, safety or personal rights risk to clients in care.
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A copy of the completed in-service training log and self certification that Administrator has read, reviewed and understood Title 22 Regs Sec 80076 must be submitted to LPA/CCL by POC due date.
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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.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025
LIC9099 (FAS) - (06/04)
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