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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603708
Report Date: 03/07/2024
Date Signed: 03/07/2024 01:44:44 PM

Document Has Been Signed on 03/07/2024 01:44 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:SAFE PLACE, THEFACILITY NUMBER:
198603708
ADMINISTRATOR:UGBEYIDE, OGHENETEGAFACILITY TYPE:
735
ADDRESS:10 ROLLING HILLS DRIVETELEPHONE:
(310) 920-5095
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 4CENSUS: 0DATE:
03/07/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Oghenetega Ugbeyide and Brittany JonesTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an announced pre-licensing visit. LPA met with Oghenetega Ugbeyide (Applicant) and Brittany Jones (Back-Up Administrator). The facility is to serve 4 non-ambulatory individuals. Applicant will be contacting San Gabriel Pomona Regional Center and inquire about vendorization. Component III was also completed during this visit.

This is a single-story home that consists of: (4) bedroom (each client will have their own bedroom), (2) bathrooms (1) of which is located inside room #4, living room, dining area, family room, kitchen, laundry room and attached garage.



The following was observed/inspected:
  • Physical plant is in good repair.
  • Building and grounds are free from hazards.
  • Smoke detectors tested and operable.
  • Carbon monoxide detector was tested and operable. Located in the hallway leading to the bedrooms.
  • Fire extinguisher (service date: 11/07/23) located in the kitchen and attached garage appeared to be full.
  • Telephone (landline) tested and operable. Per Applicant, facility has internet access.
  • Cleaning solutions (under kitchen sink) and sharps are locked in the kitchen.
  • Pantry's cupboards, freezers, stoves, microwaves, refrigerator and counters are clean.
  • Two-day supply of perishables available, seven-day supply of non-perishable available. Water supply observed.
  • The facility has dining table and sufficient chairs.
  • There is a designated space inside a kitchen cabinet for Medications to be locked.
  • First Aid Kit inspected. American Red Cross First Aid Manual observed.

**Refer to LIC 809C for the continuation of this report**
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAFE PLACE, THE
FACILITY NUMBER: 198603708
VISIT DATE: 03/07/2024
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  • Pesticides and other toxic substances are stored and locked away from food supply.
  • Bedrooms are large enough to allow for easy passage between and comfortable for usage of beds and other required items of furniture. Each client will have their own bedroom.
  • Clients have the appropriate furniture (one chair, night stand, adequate closet and drawer space).
  • Mattresses are in good repair.
  • There are enough bath towels, hand towels and wash cloths for all clients.
  • Hot water temperature measured the following: kitchen (111.0*), hallway bathroom (116.0*) and bathroom inside room #4 (115.0*).
  • Refrigerator, stove, sinks, tubs, toilets and showers operate properly. Bathrooms have non-skid mats.
  • Facility has a washer and dryer that are fully operational located near the garage.
  • Client and staff files will be locked inside the closet near the kitchen.
  • Window screens are in good repair and windows/curtains/blinds are in good repair and operate properly.
  • Outdoors: there is a shade area set up in the backyard to accommodate (4) clients.
  • Hygiene supplies observed.
  • PPE supplies observed.
  • Clients rights are posted.
  • Emergency Disaster Plan is posted.

No deficiencies observed. Exit interview conducted, copy of report provided to Oghenetega Ugbeyide (Applicant).
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC809 (FAS) - (06/04)
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