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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603616
Report Date: 02/20/2025
Date Signed: 02/20/2025 12:08:46 PM

Document Has Been Signed on 02/20/2025 12:08 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 HOME2, LLCFACILITY NUMBER:
198603616
ADMINISTRATOR/
DIRECTOR:		OSIBOGUN, OLAIDEFACILITY TYPE:
735
ADDRESS:155 W RENWICK RDTELEPHONE:
(626) 804-3418
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 4CENSUS: 3DATE:
02/20/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Olaide Osibogun- AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted a case management visit to follow-up on the death of Client 1 (C1). LPA met with Administrator Olaide Osibogun and explained the reason for the visit.

According to the death report, C1 passed away on 02/16/25. Administrator stated that the C1 was eating sandwich, on the morning of 02/16/25 at 11:52 am when C1 began choking. Facility Staff 1 (S1) performed the abdominal thrusts, while Staff 2 (S2) called 911. Paramedics came at about 11:57am and tried suctioning food about 20 minutes before C1 was taken to the hospital. C1 was transported to the hospital due to low oxygen level. C1 passed way at the hospital on 02/16/25 at 12:47pm. Administrator notified licensing, via fax, regarding the death.

During today's visit, LPA reviewed C1's file, interviewed Administrator, S1 and S2. Copies of the following documents were provided:
· Death Report LIC 624A
· Facility / Shift Note
· C1 30-day Report
· Placement Information
· C1 Face Sheet
· Resent Individual Program Plan (IPP)
· Physician's Report for Community Care Facilities LIC 602

Continue 809C
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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 2
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 HOME2, LLC
FACILITY NUMBER: 198603616
VISIT DATE: 02/20/2025
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· Functional Capability assessment
· Preplacement Appraisal Information LIC 603
· C1 Development Evaluation Report
· Copy of C1's medication record for months of 12/24, 01/25 and 02/25
· CPR/AED/First Aid and CPI Certificates for S1 and S2.

LPA also toured C1's bedroom. No concerns, obstructions, or anything out of the ordinary was witnessed during the visit. LPA requested the facility obtain a copy of the death certificate and submit it to CCL. A copy of the "Death Certificate" will be provided to CCL upon receipt.
Exit interview conducted and copy of the report was provided to Administrator.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
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