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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530008
Report Date: 02/28/2023
Date Signed: 02/28/2023 01:38:50 PM

Document Has Been Signed on 02/28/2023 01:38 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: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: DATE:
02/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Kingsley Okundaye, AdministratorTIME COMPLETED:
01:35 PM
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Licensing, Program Analyst, Amber Coleman, (LPA) arrived at the House of Solomon Adult Residential Facility to conduct a Case Management visit for Health and Safety in response to the death of a resident. LPA was greeted by Staff Member, (S1) and invited inside facility. LPA introduced self and stated purpose of the visit. LPA had temperature taken and was provided space to work.

The case management visit consisted of a walk through of facility, collection of resident documents and interviews regarding the events which led to resident's death. Administrator reported that no death certificate or documents were provided to the facility afterwards. The Police did make a visit and call the coroner. The corner then authorized the release at the request of family. No death certificate was provided to facility which lists a cause of death. Resident's next of kin was his brother. The resident had no conservator. LPA has advised the Administrator to send a copy of the death certificate the Community Care Licensing Division (CCLD) Riverside Regional Office as soon as it is available.

LPA collected the following documents:
  • Police Report Card with No.
  • Resident medication records
  • Physician's Report (LIC602)
  • Staff training records
  • Primary Care Physician Notes & contact information
  • Progress Notes

No deficiencies observed. An exit interview was conducted where this report was discussed and provided to Administrator, Kinsley Okundaye.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2023
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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