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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804214
Report Date: 04/05/2024
Date Signed: 04/05/2024 12:19:50 PM

Document Has Been Signed on 04/05/2024 12:19 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HUMUCARE INC - FIELDCREST AVEFACILITY NUMBER:
486804214
ADMINISTRATOR/
DIRECTOR:		KUKU, OLUKEMIFACILITY TYPE:
735
ADDRESS:2160 FIELDCREST AVENUETELEPHONE:
(714) 323-3822
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 4CENSUS: 0DATE:
04/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:39 AM
MET WITH:Olukemi Kuku, Licensee ApplicantTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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On 4/5/2024 Licensing Program Analysts LPA's) Tobola and Matialu conducted a pre-licensing inspection and was greeted by Licensee Applicant, Olukemi Kuku. This pre-licensing inspection is being conducted for an initial licensing. Fire Clearance has been approved for 4 ambulatory clients. Licensee Applicant is currently in partnership with North Bay Regional Center and in the process of starting vendorizing for client placement upon issue of license.

LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. Facility was found to be clean and comfortable temperature with bedroom doors free from obstruction. LPA's observed Fire extinguishers throughout the facility were found to be recently purchased. Smoke detectors and carbon monoxide detectors were tested in common areas and client bedrooms all of which were found to be in working order. Emergency exits along the one side of the facility have appropriate hardware and found to be unobstructed. Water was measured between 106.1 & 108.1 degrees F in faucets used by clients which falls within regulation between 105 & 120 degrees F.

There was an ample supply of linens with appropriate bedding equipped in client rooms. An additional supply of hygiene, continence and paper products are located in a secured cabinet in client bathroom. Stairs and hallways are equipped with several night lights for accessibility and client bedrooms have appropriate furnishings. There is a sufficient amount of dishes and cooking supplies for client use with sharps and other hazardous items kept secured in various designated drawer and cabinets as well as under the kitchen sink. Cleaning products and other toxins and chemicals are kept out of client access and found secured in the garage and laundry room cabinets and kitchen area. LPA's observed adequate supply of both perishable and non-perishable food sufficient for the 4 clients in care. The facility will be conducting weekly grocery replenishment with consideration to client preferences and dietary restrictions. A sample menu will be posted on the refrigerator to indicate a healthy and balance set of meals for clients in care.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HUMUCARE INC - FIELDCREST AVE
FACILITY NUMBER: 486804214
VISIT DATE: 04/05/2024
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Medications are centrally stored and secured in locked cabinets located front office with Centrally Stored Medication Records and several other medication related forms on file. The facility will be creating hard copy files for all client specified documents including care plans, medical reports and dietary restrictions. Licensee applicant to also ensure hard copies of appropriate staffing records, program operation documentation and emergency disaster information to be on file. Licensee Applicant indicated that they have all licensing document templates ready on file. The facility has all appropriate public documentation and personal rights information posted in common spaces and hallways within the facility. The facility has begun the hiring process for direct support staff and have been informed of association process.

The backyard features a large yard and deck with shaded seating for client outdoor use. The facility has supplies of additional recreational items and activities for client use upon admission. Windows and blinds are all found to be in good repair. LPA's observed two window screens located in one staff and one client bedroom in need of replacement or repair. Emergency evacuation maps and clear exit signs are posted appropriately. Infection control plan has been updated and protocol infection prevention information to be posted at the entrance, common areas and bathrooms. A sign in sheet with proper screening devices and protection equipment were also observed at the front entrance. The facility and facility operation plan are found to be adequate and tour of the facility completed.

Licensee will be sending a copy of the liability insurance to CCLD once completed. Component III orientation was conducted with the Licensee Applicant. The pre-licensing evaluation has been completed. License will be granted upon completion of a final review and approval from the Licensing Program Manager. This report was reviewed with applicant and a copy was provided to the Licensee.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC809 (FAS) - (06/04)
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