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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530008
Report Date: 10/31/2022
Date Signed: 10/31/2022 11:39:12 AM

Document Has Been Signed on 10/31/2022 11:39 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HOUSE OF SOLOMON RESIDENTIAL FACILITYFACILITY NUMBER:
365530008
ADMINISTRATOR:OKUNDAYE, KINGSLEYFACILITY TYPE:
735
ADDRESS:2962 NORTH RIVERSIDE AVETELEPHONE:
(609) 782-9138
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 4CENSUS: 1DATE:
10/31/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Kinglsey Okundaye, AdministratorTIME COMPLETED:
11:40 AM
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LPA's Amber Coleman (LPA Coleman) and LPA Anna Bueno (LPA Bueno) made an unannounced visit to conduct a post licensing visit.

Administrator answered the door and invited LPAs inside facility. LPAs made introductions and discussed the purpose of the visit. LPA's completed a walk through the facility and observed the following.

LPA's temperature was taken upon arrival and COVID station was observed during arrival. LPA's requested Administrator provide LPAs with a walk through of the home. The home was observed to be free of clutter and debris in comfortable temperature. At the time of the visit, current census was 1 and 2 staff members present. The home was cleanly, orderly free of debris and in comfortable temperature. The facility met the standard operational requirements.

However, during the walk through of the backyard area, the perimeter side gate was observed to be locked with a chain and pad lock. licensee has plan in place to repair perimeter gate prior to visit. A technical violation will be issued for Licensee to address gate repair.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2022
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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