365530008-8-9-2022-56-AS-BALN-CH5PCU-20220809111232

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530008
Report Date: 08/09/2022
Date Signed: 08/09/2022 11:13:26 AM

Document Has Been Signed on 08/09/2022 11:13 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	HOUSE OF SOLOMON RESIDENTIAL FACILITY		FACILITY NUMBER:	365530008
ADMINISTRATOR:	OKUNDAYE, KINGSLEY		FACILITY TYPE:	735
ADDRESS:	2962 NORTH RIVERSIDE AVE		TELEPHONE:	(609) 782-9138
CITY:	RIALTO	STATE: CA	ZIP CODE:	92377
CAPACITY: 4		CENSUS: 0	DATE:	08/09/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:23 AM
MET WITH:	Kingsley Okundaye- Administrator		TIME COMPLETED:	11:20 AM

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Licensing Program Analyst (LPA) Bernadette Allen conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPA Allen was granted entry. LPA met with Kingsley Okundaye- Administrator LPA observed the following

Structure:

The facility is a two story house with four (4) resident bedrooms, three(3) bathrooms, living room, dining area and kitchen. Office area at front entry, attached two car garage in the front of the house.

Heating/Cooling System:

Central heating and air conditioning system installed with a central panel located in the dining area.

Bedrooms:

Resident bedroom #1, is located on the first floor near the dining area. Bedroom #2, #3 and # 4 are on the second level and all rooms will only accommodate ambulatory residents. All bedrooms are furnished with adequate furniture, bed, chair, closet, appropriate linens, adequate lighting.

Bathrooms:

There are three (3) bathrooms all have a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. LPA tested the water temperatures in the Master bathroom that measured at 114.9 degrees Fahrenheit.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. There were no knives/sharp instruments during the visit, but LPA was shown were the knives/ sharps would be stored in the garage in a locked cabinet. There was adequate room for food and storage.

Continued

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: HOUSE OF SOLOMON RESIDENTIAL FACILITY	FACILITY NUMBER: 365530008
	VISIT DATE: 08/09/2022

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LPA observed the stove to be operational. Refrigerator/freezer were in working condition with 5 days of perishables and 7 days of non-perishable food items. There was adequate seating for meals for all clients.

Laundry detergents were observed locked in the laundry room and in garage secured in a locked cabinet.

General items:

LPA observed that the fire extinguishers were fully charged, and carbon monoxide detectors were in working condition

Living/Family room:

LPA observed the living/family room with adequate seating for all clients to watch TV and activities. LPA also observed that there was a working telephone line during the visit.

Linens and Hygiene Supplies:

LPA observed an adequate supply of linens and hygiene supplies were stored in a cabinet in the main hallway on both levels of the home.

Yards/Outside:

LPA observed a shaded area with adequate seating for clients, staff, or visitors. There was no body of water observed during the visit.

Emergency Phone Numbers, and Exit Plan:

LPA observed facility sketch and Let-Us-No poster in the main entrance of the house.

LPA observed the First Aid kit with required components, and medications will be stored., LPA also observed where P & I, staff and residents files will be stored in the office in locked cabinets.

An exit interview was conducted, and a copy of this report was given to the Kingsley Okundaye- Administrator

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

LIC809 (FAS) - (06/04)

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