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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604628
Report Date: 12/12/2023
Date Signed: 12/12/2023 12:31:21 PM

Document Has Been Signed on 12/12/2023 12:31 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:YAI GARJAN LANE ENHANCED BEHAVIORAL SUPPORTS HOMEFACILITY NUMBER:
374604628
ADMINISTRATOR:AJETUNMOBI, OLAYINKAFACILITY TYPE:
737
ADDRESS:17106 GARJAN LANETELEPHONE:
(646) 946-1389
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY: 4CENSUS: 0DATE:
12/12/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Program Administrator Olayinka Ajetunmobi.TIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Amy Rodgers conducted an announced Pre-Licensing and Component III visit at a Residential Care Facility for the Adults (ARF) to ensure compliance with California Code of Regulations, Title 22, Division 6 and the Health and Safety Code. LPA was greeted by, identified herself to, and explained the purpose of the visit to the Program Administrator Olayinka Ajetunmobi.

The facility fire clearance was granted on 11/27/2023 and reflected that the facility was approved for four (4) residents in total, of which two (2) may be non-ambulatory. The facility's fire clearance did include delayed-egress door or secured perimeter endorsements and were present during today's visit. The submitted facility sketch was consistent with the current layout of the facility.


During today’s visit, LPA, accompanied by Program Administrator Ajetunmobi, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. The pathways were well lit and free of obstruction and slip hazards. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets, sinks, and showers were in working order. The facility’s ambient internal temperature was compliant. Hot water temperature at taps accessible to residents were also compliant.

The facility has enough linens, hygiene supplies, cooking and dining supplies, and perishable and non-perishable food for future resident use. All kitchen appliances were in working order. Refrigerator and freezer temperatures were within regulatory range.

[CONTINUED on 809-C]

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: YAI GARJAN LANE ENHANCED BEHAVIORAL SUPPORTS HOME
FACILITY NUMBER: 374604628
VISIT DATE: 12/12/2023
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[CONTINUED from 809]

The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of sharp objects, medication, and confidential resident and staff records.

No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per Program Administrator Ajetunmobi, no firearms or ammunition are or will be stored at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all observed and operational. A complete first aid kit was present. Required licensing postings were observed in visible areas of the facility.

Component III was conducted at the facility with Program Administrator Ajetunmobi and Board Certified Behavior Analyst Edgar Jimenez. LPA reviewed continuing operational requirements, as well as record keeping and physical plant compliance. The items reviewed were complaint with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. The applicant passed the pre-licensing inspection and was advised that the facility’s application is pending management final review and approval.


An exit interview was conducted and a copy of this report and Licensee/Appeal Rights - LIC 9058 (rev. 01/16) were provided to the Program Administrator Ajetunmobi, whose signature on this form acknowledges receipt of these documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC809 (FAS) - (06/04)
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