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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530008
Report Date: 12/30/2022
Date Signed: 12/30/2022 12:22:16 PM

Document Has Been Signed on 12/30/2022 12:22 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:
12/30/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kinsley Okundaye, AdministratorTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst, Amber Coleman (LPA) arrived at the facility for a Case Management Visit to address lock on gate. During a previous visit, Administrator stated that the gate has equipped with a chain due to a resident breaking the gate leaving staff unable to secure the gate to prevent intruders. LPA introduced self and stated purpose of the visit. Administrator Kingsley Okundaye, granted LPA entry to facility.

Administrator then took LPA to the side gate in question. Administrator explained that the gate was fixed. LPA observed the gate with 2 deadbolt locks vertically situated on the fence. LPA explained that the gate cannot be locked because it may not allow residents and/or staff to leave the premises in the event of an emergency.

An exit interview was conducted where this report, LIC-809D, and appeal rights were discussed and provided to Administrator Kinsley Okundaye via email.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2022
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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Document Has Been Signed on 12/30/2022 12:22 PM - It Cannot Be Edited


Created By: Amber Coleman On 12/30/2022 at 12:08 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
RIVERSIDE, CA 92507

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/30/2022
Section Cited
HSC
80087(i)

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Health and Safety Code section 1531.15 provides in pertinent part:
(i) Interior and exterior space shall be available on the facility premises to permit clients to move freely and safely
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Licensee shall keep both side gates secured but not locked in any capacity. If Licensee wishes to keep gates locked, Licensee shall submit proof to the Department that requirements as outlined in CCR Section 80087(i)
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This requirement was not met as evidenced by: LPA observing 2 vertically situated locks on the side exterior gate to the facility.
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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:Nedra Brown
LICENSING EVALUATOR NAME:Amber Coleman
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2022


LIC809 (FAS) - (06/04)
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