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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604628
Report Date: 03/01/2024
Date Signed: 03/01/2024 07:58:35 PM

Document Has Been Signed on 03/01/2024 07:58 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:
6469461389
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY: 4CENSUS: 2DATE:
03/01/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:41 PM
MET WITH: Assistant Regional Director Mitch BlackwoodTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Manager (LPM) Simon Jacob and Licensing Program Analyst (LPA) Amy Rodgers made an unannounced visit to the facility to conduct a post-licensing inspection. LPA was met by Assistant Regional Director Mitch Blackwood and granted entry into the facility and discussed the purpose of the visit.

A tour of the facility was conducted inside and out. LPM and LPA, accompanied by Mr. Blackwood conducted a general overall inspection, which included, but was not limited to the following: Facility physical plant, food service, care and supervision, medication, record review and facility administration. Administrator Certificate for Olayinka Ajetunmobi expires on May 19, 2025.

During today's inspection, LPA observed the following: All indoor and outdoor passageways were free from obstructions. No pools or bodies of water were observed. Per Blackwood, there are no firearms or other dangerous weapons in the facility. Poisons and cleaning agents were observed to be inaccessible to clients in care. LPA toured each room in the facility. Rooms designated as client bedrooms had the required furnishings and sufficient lighting available for clients. Licensee provided each client with clean linen in good repair and sufficient hygiene products for personal use. The hot water temperature measured at 105-120 degrees F. The facility had multiple functioning carbon monoxide detectors and multiple smoke detectors. There was an operable fire extinguisher present in the facility. The facility was stocked with a two (2) day supply of perishable and seven (7) day supply of nonperishable food items. Medications were stored in a locked medication cart and were labeled and maintained in compliance with label instructions.

Based on today's visit, deficiencies were observed and cited at this time of the visit. A copy of this report, along with the 809-Ds, and Licensee/Appeal Rights, was provided to Mr. Blackwood at the conclusion of the visit, and signature on this form acknowledges receipt of these rights.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2024
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 03/01/2024 07:58 PM - It Cannot Be Edited


Created By: Amy Rodgers On 03/01/2024 at 04:49 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: YAI GARJAN LANE ENHANCED BEHAVIORAL SUPPORTS HOME
FACILITY NUMBER: 374604628

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85079(a)
Activities
(a) The licensee shall ensure that planned recreational activities, which include the following, are provided for the clients:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 2 of 2 clients which poses/posed a potential personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Licensee will provide proof of client specific planned activities by POC date 3/15/24.
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above in 2 out of 2 clients in care which poses/posed a potential health and safety risk to persons in care.
POC Due Date: 04/01/2024
Plan of Correction
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The Licensee will provide the LPA proof of completion of shade to the existing pergula or an umbrella or awning that would provide shade to clients in care.
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:Denise Powell
LICENSING EVALUATOR NAME:Amy Rodgers
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/01/2024 07:58 PM - It Cannot Be Edited


Created By: Amy Rodgers On 03/01/2024 at 04:49 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: YAI GARJAN LANE ENHANCED BEHAVIORAL SUPPORTS HOME
FACILITY NUMBER: 374604628

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(2)
Personal Rights
(a) Except for children's residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above in 2 out of 2 clients in care which poses/posed a potential personal rights risk to persons in care.
POC Due Date: 04/01/2024
Plan of Correction
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The Licensee will have the common areas and of the facility furnished and have persons centered and home like touches throught the faciliites by 4/1/24. The Licensee states that the furniture has already been ordered and will be arriving in the next few weeks.
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:Denise Powell
LICENSING EVALUATOR NAME:Amy Rodgers
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2024


LIC809 (FAS) - (06/04)
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