198603616-1-26-2023-28-AS-JBAE-CNFRGC-20230126120031

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603616
Report Date: 01/26/2023
Date Signed: 01/26/2023 12:00:38 PM

Document Has Been Signed on 01/26/2023 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	OLUWATOYIN HOME 2, LLC		FACILITY NUMBER:	198603616
ADMINISTRATOR:	OSIBOGUN, OLAIDE		FACILITY TYPE:	735
ADDRESS:	155 W RENWICK RD		TELEPHONE:	(626) 804-3418
CITY:	AZUSA	STATE: CA	ZIP CODE:	91702
CAPACITY: 4		CENSUS: 0	DATE:	01/26/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Administrator Olaide Osibogun		TIME COMPLETED:	12:15 PM

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On 1/26/2023 at 9:50 a.m., Licensing Program Analyst (LPA) Jewel Baptiste made an announced visit and met with Administrator Olaide Osibogun to conduct a pre-Licensing evaluation. The facility will not have clients immediately due to application process to receive regional center clients. LPA explained to administrator, once the facility is licensed the home will have to operate under title 22 regulations while waiting on regional center clients.

An application was submitted to Community Care Licensing Department (CCLD) for an initial application of an Adult Residential Facility Community Placement Plan (CPP) home to serve adults ages 18-59 years, level 4n. The requested capacity is for four (4) ambulatory developmentally disabled clients. Structure: Facility is a single-story home consisting of four (4) bedrooms, two (2) restrooms, kitchen, dining room, living room, garage. The front yard has a grass lawn. The backyard has shaded patio area. Bedroom Clients: All bedrooms are private. Bedrooms are equipped with one bed, nightstand, chair, lamp, and lightning. Bathrooms: Have a working toilet, wash basin, and bathtub. Linens & Hygiene Supplies: All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linens is stored in the hall closet. Emergency Phone Numbers, Exit Plan: Emergency numbers are posted and readily available for review. Two (2) fully charged fire extinguisher is in place. Facility has a land line telephone. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils were observed locked and inaccessible. Adequate food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables.

Report continued on 809c

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OLUWATOYIN HOME 2, LLC	FACILITY NUMBER: 198603616
	VISIT DATE: 01/26/2023

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Smoke Detectors: There are electrical & inter-connected smoke detectors located in all bedrooms, common areas, and hallways. Appliances: Refrigerator, oven, microwave, dishwasher, and washer/dryer were observed. The residence is equipped with central heating and air conditioning. Toxins: Cleaning supplies, and toxins are locked only accessible to staff. Water Temperature: Hot water was tested in all bathrooms, and kitchen sink. Water temperature was within normal limits 105 degrees Fahrenheit (40.5 degrees C) and not more than 120 degrees Fahrenheit (48.8 degrees C). Medication, First-Aid Kit & Book: Designated centrally stored medications are stored in locked file cabinets. The first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual. Clients & Staff Files: Designated area for files will be in the locked file cabinets. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance was approved on 10/28/2022 for four (4) ambulatory clients. The facility has no delayed egress. Component III: Component III was waived. Applicant is a current licensee of same category facility. All corrections was made during the visit. No corrections is needed.

An exit interview was conducted, and a copy of this report has been provided to Administrator Olaide Osibogun. LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC809 (FAS) - (06/04)

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