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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530008
Report Date: 08/08/2024
Date Signed: 08/08/2024 04:47:06 PM

Document Has Been Signed on 08/08/2024 04:47 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:HOUSE OF SOLOMON RESIDENTIAL FACILITYFACILITY NUMBER:
365530008
ADMINISTRATOR/
DIRECTOR:		OKUNDAYE, KINGSLEYFACILITY TYPE:
735
ADDRESS:2962 NORTH RIVERSIDE AVETELEPHONE:
(609) 782-9138
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 4CENSUS: 4DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Administrator Kingsley OkundayeTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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On 08/08/2024 at 01:50 PM, Licensing Program Analysts (LPAs) Melody Brown and Becky Mann conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPAs Brown and Mann were greeted by Administrator Kingsley Okundaye and gained access at the home. LPAs Brown and Mann explained the purpose of the visit to Administrator Kingsley Okundaye .

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPAs Brown and Mann 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 Mann observed four (4) clients during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 77 degrees Fahrenheit. LPAs Brown and Mann inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPAs Brown and Mann inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 110 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 Mann observed no non-slip mat on clients bathroom. deficiency will be issued.

Posters such as; the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPAs Brown and Mann 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.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: 08/08/2024
NARRATIVE
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Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPAs Brown and Mann 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 Mann reviewed three (3) client files for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP). LPAs Brown and Mann observed files reviewed were complete. LPAs Brown and Mann also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPAs Brown and Mann observed Staff #3 (S3) does not have Health Screening Report in S3 file. Deficiency will be issued. Also, S3 does not have completed CPR/First Aid Certification in S3 file. Deficiency will be issued.

LPAs Brown and Mann audited three (3) clients’ medications and no issues were observed. LPAs Brown and Mann audited three (3) client's Personal and Incidental (P&I) and no issues observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809D, and (Appeal Rights) were discussed, and copies were provided to Administrator Kingsley Okundaye .

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/08/2024 04:47 PM - It Cannot Be Edited


Created By: Melody Brown On 08/08/2024 at 04:27 PM
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
, CA 92507

FACILITY NAME: HOUSE OF SOLOMON RESIDENTIAL FACILITY
FACILITY NUMBER: 365530008

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

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 ensuring that Staff #3 (S3) completed the required Health Screening Report prior to employment which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Licensee stated to submit to LPA Brown medical appointment for S3 to complete the required Health screening Report on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

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 ensuring that Staff #3 (S3) completed the required First Aid/CPR Training from persons qualified by agencies including but not limited to American Red Cross which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Licensee stated to submit proof to LPA Brown of S3 enrollment/registration to complete the required CPR/First Class on POC due date.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/08/2024 04:47 PM - It Cannot Be Edited


Created By: Melody Brown On 08/08/2024 at 04:27 PM
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
, CA 92507

FACILITY NAME: HOUSE OF SOLOMON RESIDENTIAL FACILITY
FACILITY NUMBER: 365530008

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(b)(1)
Building and Grounds
(b) All clients shall be protected against hazards within the facility through provision of the following: (1) Protective devices including but not limited to nonslip material on rugs.

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 ensuring that there are non-slip mat on clients bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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LIcensee stated to obtain/purchase non-slip mat and submit proof to LPA Brown on 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


LIC809 (FAS) - (06/04)
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