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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881280
Report Date: 06/02/2023
Date Signed: 06/02/2023 12:53:00 PM

Document Has Been Signed on 06/02/2023 12:53 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:OLUWATOYIN HOME, LLCFACILITY NUMBER:
331881280
ADMINISTRATOR:SOLOMON OLOWOFACILITY TYPE:
735
ADDRESS:1777 VIA VERDE DRIVETELEPHONE:
(909) 320-7971
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 4CENSUS: 1DATE:
06/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Chinelo "Chi Chi" Ogugoa, Staff MemberTIME COMPLETED:
01:00 PM
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Licensing Program Analyst, Amber Coleman (LPA) arrived at the Oluwatoyin Home Adult Residential Facility unannounced to conduct an Annual Inspection. LPA knocked on the door and was greeted by Staff Member, Chi Chi and invited inside the facility. LPA stated the purpose of the visit. Ms. Chi Chi contacted the Administrator to notify them of LPA's visit. It was reported that the facility accepted their first resident a month prior. The current census is 1.

The facility consists of 2 stories. It has 3 client rooms, 2 staff rooms, 2 bathrooms, living room, dining room, a den, backyard and attached garage. The facility is vendorized by the Inland Regional Center, level 4I. LPA conducted 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 indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were operating appropriately. LPA tested the temperature from the bathroom faucet, which ranged between 103 and 112 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as; the personal rights and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept in a securable laundry space. Staff and resident files and medications are kept in the kitchen nook; inside secure file cabinets. The facility had emergency and first aid kits readily available for clients in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.
Food Service: Non-perishable and perishable food supply is sufficient for number of clients residing in the facility. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.
Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.
Record Review: At approximately 11:45am, LPA requested the resident and staff files. Staff member contacted the Administrator to make the request. Administrator reported the resident's file was not complete as it was at the doctor's office to be completed. A request was made to the Doctor's office to get this form completed. LPA reviewed 1 resident file for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 1 staff file for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited and appeared to be dispensed appropriately by staff. Fire extinguisher last inspected February 2023.

Based on observations, a deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Licensee; signature acknowledges understanding and receipt of report and attachments.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
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 06/02/2023 12:58 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/02/2023 12:55 PM


Created By: Amber Coleman On 06/02/2023 at 12:36 PM
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: OLUWATOYIN HOME, LLC

FACILITY NUMBER: 331881280

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of the resident record the licensee did not comply with the section cited above by not ensuring the resident in care possessed all regulated documents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2023
Plan of Correction
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Administrator/Licensee will obatin the resident's LIC602 form from the resident's Primary Care Physician by 6/16/2023. Adminstrator/Licensee will submit verification of receiving this form to the Community Care Licensing
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Amber Coleman
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023


LIC809 (FAS) - (06/04)
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