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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881280
Report Date: 05/17/2024
Date Signed: 05/17/2024 12:09:10 PM

Document Has Been Signed on 05/17/2024 12:09 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:OLUWATOYIN HOME, LLCFACILITY NUMBER:
331881280
ADMINISTRATOR/
DIRECTOR:		OLUWATOYOSI ADERONMUFACILITY TYPE:
735
ADDRESS:1777 VIA VERDE DRIVETELEPHONE:
(909) 320-7971
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 4CENSUS: 3DATE:
05/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Licensee/Administrator Olaide OsibogunTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 05/17/2024 at 8:55 AM, Licensing Program Analysts (LPAs) Sarina Ramirez and Melody Brown conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPAs Ramirez and Brown were greeted by a staff and gained access of the home. Licensee/Administrator Olaide Osibogun was contacted, informed, and arrived during the visit. LPAs Ramirez and Brown explained the purpose of the visit to Licensee/Administrator Osibogun.

The facility has five (5) bedrooms, three (3) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPAs Ramirez and Brown completed a walkthrough of the facility, review of records, and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Ramirez and Brown observed one(1) client during the visit. Two (2) clients’ out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPAs Ramirez and Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPAs Ramirez and Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 115 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPAs Ramirez and Brown observed no night lights at the hallway leading to clients' shared bathrooms, deficiency will be issued. The facility had emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: OLUWATOYIN HOME, LLC
FACILITY NUMBER: 331881280
VISIT DATE: 05/17/2024
NARRATIVE
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Yards/Outside: One shaded patio, two (2) side gates with self-latching handle on the left and right side of the house that leads into the backyard, attached one (1) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPAs observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


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

Record Review: LPAs Ramirez and Brown reviewed two (2) client files for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP). LPAs Ramirez and Brown observed files reviewed were complete. LPAs Ramirez and Brown also reviewed four (4) staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, CPI and health screenings with tuberculosis (TB) test result. LPAs Ramirez and Brown observed staff #1 (S1) does not have updated CPI certification, deficiency will be provided.

LPA Brown audited two (2) clients’ medications and Client #2 (C2) was administered medications, however Staff did not sign MAR. LPAs Ramirez and Brown audited two (2) client's P&I and no issue observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, (LIC809D), and (Appeal Rights) were discussed, and copies were provided to Licensee/Administrator Olaide Osibogun.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/17/2024 12:09 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 05/17/2024 at 11:24 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: OLUWATOYIN HOME, LLC
FACILITY NUMBER: 331881280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not updating client #2 (C2) medication administration record. (MAR) after dispensing C2 medication per doctors order staff did not sign, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2024
Plan of Correction
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Licensee stated to train all staff on CCR 80075(b)(5)(B) and submit proof of all staff training log to LPAs Ramirz and Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
85165(b)(2)
Emergency Intervention Staff Training
(b) Staff who use, participate in, approve or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified for having successfully completed the training. (2) Staff shall maintain valid certification.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not having an updated CPI Certification for Staff #1 (S1) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2024
Plan of Correction
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Licensee stated to submit proof of registration/enrollment or updated CPI certificate to LPAs Ramirez and Brown by POC due date.
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:Karen Clemons
LICENSING EVALUATOR NAME:Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/17/2024 12:09 PM - It Cannot Be Edited


Created By: Sarina Ramirez On 05/17/2024 at 11:54 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: OLUWATOYIN HOME, LLC
FACILITY NUMBER: 331881280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
85088 Fixtures, furniture, equipment & supplies (e) emergency lighting, which shall include at a minimum working...(2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not maintaining night lights in hallways and passages to nonprivate bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Licensee stated to purchase night lights and submit proof to LPAs Ramirez and Brown by the Plan of Correction (POC) due date.
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:Karen Clemons
LICENSING EVALUATOR NAME:Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024


LIC809 (FAS) - (06/04)
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