331880820-10-30-2023-56-AS-RGAR-CX4P7T-20231030110427

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880820
Report Date: 10/30/2023
Date Signed: 10/30/2023 11:04:33 AM

Document Has Been Signed on 10/30/2023 11:04 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	YEMMA CARE HOME INCORPORATION		FACILITY NUMBER:	331880820
ADMINISTRATOR:	OYEBOBOLA, OLAYEMI		FACILITY TYPE:	735
ADDRESS:	24507 POINSETTIA DRIVE		TELEPHONE:	(818) 213-8485
CITY:	LAKE ELSINORE	STATE: CA	ZIP CODE:	92532
CAPACITY: 4		CENSUS: 3	DATE:	10/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Olayemi Oyebobola- Administrator		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Olayemi Oyebobola and was granted entry to the facility. At the time of the visit there were three (3) staff present and one (1) client present. The facility is a five (5) bedroom, three (3) bathroom home with a kitchen/dining area, living room, and attached garage. The facility is an Adult Residential Facility (ARF) level 4i home vendorized by Inland Regional Center. The facility is licensed for a capacity of four (4) clients and the current census is three (3) clients. LPA was accompanied by Administrator to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to the indoor and exterior passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathroom to be at 105.9 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications are kept inside medication cabinet inaccessible to clients. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

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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Document Has Been Signed on 10/30/2023 11:04 AM - It Cannot Be Edited

Created By: Ryan Gardner On 10/30/2023 at 10:29 AM

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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: YEMMA CARE HOME INCORPORATION	FACILITY NUMBER: 331880820
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80069(b)

Client Medical Assessments

(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, observation, and document review, the licensee did not comply with the section cited above evidenced by not having medical assessments for Client C1 and Client C2 which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 11/10/2023
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 80069 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to schedule a doctor’s appointments for Client C1 and Client C2 to obtain updated medical assessments. The licensee has agreed that moving forward the clients in care will have a yearly medical assessment and the documents will be on file at the facility. POC is due by 11/10/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Efren Malagon

LICENSING EVALUATOR NAME:

Ryan Gardner

LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: YEMMA CARE HOME INCORPORATION	FACILITY NUMBER: 331880820
	VISIT DATE: 10/30/2023

NARRATIVE

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Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed three (3) client files for admission agreements, updated physician reports, and needs and services plans. Two (2) out of three (3) clients do not have physician reports in their files. The facility will be issued a deficiency for not having physicians reports for Client C1 and Client C2. LPA reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications/MARs records were audited and appeared to be dispensed appropriately by staff members.

Based on the observations made during today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D, LIC811, and the appeal rights were discussed and provided to Administrator Olayemi Oyebobola.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

LIC809 (FAS) - (06/04)

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