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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881302
Report Date: 09/23/2024
Date Signed: 09/23/2024 11:26:34 AM

Document Has Been Signed on 09/23/2024 11:26 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PASSIONATE HOME 1FACILITY NUMBER:
331881302
ADMINISTRATOR/
DIRECTOR:		FADIPE, SUNDAY D.FACILITY TYPE:
735
ADDRESS:29340 GRAND SLAMTELEPHONE:
(347) 698-9678
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 4CENSUS: 1DATE:
09/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Innocent OkwudifeleTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 09/23/2024 at 09:05 AM, Licensing Program Analysts (LPAs) Melody Brown and Eldin Serrano conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPAs Brown and Serrano were greeted by Staff Innocent Okwudifele and gained access at the home. LPAs Brown and Serrano explained the purpose of the visit over the phone to Administrator Ijabadenuyi Olajumoke .

The facility has four (4) bedrooms, three (3) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). The facility are licensed for 4 of which can be ambulatory. LPAs Brown and Serrano completed a walkthrough of the facility, review of records, Personal and Incidental (P&I) and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Brown and Serrano observed zero (0) client during the visit. Staff Innocent Okwudifele reported to LPAs Brown and Serrano that Client #1 (C1) was not at the home since 09/22/2024 as C1 was transported to the hospital. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 78 degrees Fahrenheit. LPAs Brown and Serrano inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPAs Brown and Serrano inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 109 degrees Fahrenheit. The facility is equipped with operational combined smoke detectors and carbon monoxide detectors, charged fire extinguishers, and first aid kit with first aid book. In addition, LPAs Brown and Serrano observed non-slip mat on client’s bathroom.

*** Continuation in LIC809C ***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PASSIONATE HOME 1
FACILITY NUMBER: 331881302
VISIT DATE: 09/23/2024
NARRATIVE
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Posters such as the personal rights, CCLD complaint poster, and emergency disaster plan, and Labor laws were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPAs Brown and Serrano observed night lights at the hallway leading to clients' shared bathrooms. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the right side of the house that leads into the backyard, attached three (3) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPAs Brown and Serrano 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 Brown and Serrano reviewed one (1) client files for admission agreements, medical assessments/physician reports, centrally stored medication lists and Individual Program Plan (IPP). LPAs Brown and Serrano observed that client one (C1) does not have the required medical assessment/physicians report on file. Licensee/Administrator Ijabadenuyi was informed via telephone call that deficiency will be issued as medical assessment/physician report must be obtained by the licensee prior to admitting C1 to the facility on 04/17/2024. Licensee/Administrator Ijabadenuyi verbalized understanding. LPAs Brown and Serrano also reviewed staff and administrator's file for First Aid/CPR and CPI certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result.

LPAs Brown and Serrano audited one (1) client medications and no issues were observed. LPAs Brown and Serrano audited one (1) client's Personal and Incidental (P&I) and no issues observed.

Deficiency was cited during this visit. An exit interview was conducted where this report LIC809, LIC 809D and Appeal Rights were discussed, and copies were provided to Staff Innocent Okwudifele.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/23/2024 11:26 AM - It Cannot Be Edited


Created By: Eldin Serrano On 09/23/2024 at 11:07 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: PASSIONATE HOME 1
FACILITY NUMBER: 331881302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not obtaining the required medical assessment/physician report for client 1 (C1) prior to admission on 4/17/2024 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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Licensee stated to obtain medical appointment for C1 to complete the required medical assessment/physician report and submit to LPA Serrano 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:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024


LIC809 (FAS) - (06/04)
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