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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800446
Report Date: 10/19/2023
Date Signed: 10/19/2023 02:44:37 PM

Document Has Been Signed on 10/19/2023 02:44 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MH&O FAMILY HOMEFACILITY NUMBER:
361800446
ADMINISTRATOR:IDOWU, WESLEYFACILITY TYPE:
735
ADDRESS:1465 W. WEDGEWOOD STREETTELEPHONE:
(909) 421-0902
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 4CENSUS: 0DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Opeyemi Ibitoya, CaregiverTIME COMPLETED:
02:45 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the MH&O Adult Residential Facility, unannounced to conduct an Annual Inspection. LPA knocked on the door and was greeted by Opeyemi Ibitoya, Caregiver. LPA introduced self and stated purpose of the visit. LPA was granted entry and provided space to work. Administrator, Wesley Monday arrived later and accompanied LPA on a walk through of the facility and provided LPA records for review.

The facility is comprised of 3 resident bedrooms, 1 staff room, 2 bathrooms, kitchen, dining area, living room, attached garage, and backyard. The facility is vendorized with the Inland Regional Center and designated Level 4D. LPA conducted a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is approved for four, (4) Ambulatory Adults. The current census was 0, staff reported all residents were attending their day program at the time of visit. The facility is operating at the capacity approved by Community Care Licensing (CCL). Pathways were observed to be free of clutter and obstruction. The facility observed in comfortable temperature at 75 degrees. LPA inspected resident bedrooms and found that each room contained required furniture such as: mattresses, night stands, adequate storage and sufficient lighting. Night-lights were also observed throughout the facility to provide sufficient lighting at night. LPA inspected resident bathrooms; each bathroom included adequate hand hygiene supplies and operational appliances. LPA tested the temperature from the kitchen faucet, which ranged 102-109 degrees. smoke and carbon monoxide alarms were tested during the visit; and found to be functional.
Administrator reports the facility and staff run disaster drills monthly. Posters such as; the personal rights, letusknow, licensing documents and disaster/evacuation plans were posted in a common areas. Cleaning
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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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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: MH&O FAMILY HOME
FACILITY NUMBER: 361800446
VISIT DATE: 10/19/2023
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supplies, toxins, sharps, and other dangerous items were observed to be kept in secure cabinets and drawers; inaccessible to unauthorized individuals. Medications, sharp objects and staff resident files are kept in a secure desk. Emergency supplies, personal protective equipment, and first aid kits were observed and readily available for residents 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 and in good standing for the number of residents in care. Facility offers its resident a variety of food and snack items. Adequate amounts of dishes, cups, and utensils were observed in proper storage. Emergency food and water supply were also observed.
Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff files contained verifications for criminal/fingerprints record clearances through the department.
Record Review: LPA reviewed 2 resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 2 staff file for First Aid/CPR certification, criminal record clearance, training, and health screenings. Fire extinguisher last inspected November 2022

Based on observations, interviews and record reviews no deficiencies will be cited per Title 22, California Code of Regulations. A Technical Violation is being issued to address the locked fence. A copy of this report was read/reviewed with Facility Representative; signature acknowledges understanding and receipt of report and attachments.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
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