198603945-4-23-2026-28-AS-LDLN-DTERKA-20260423130512

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603945
Report Date: 04/23/2026
Date Signed: 04/23/2026 01:05:20 PM

Document Has Been Signed on 04/23/2026 01:05 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	BLOOMORA GROVE		FACILITY NUMBER:	198603945
ADMINISTRATOR/ DIRECTOR:	OKORAFOR, OGOCHUKWU		FACILITY TYPE:	740
ADDRESS:	1760 BUCHANAN DRIVE		TELEPHONE:	(909) 629-1829
CITY:	POMONA	STATE: CA	ZIP CODE:	91767
CAPACITY: 6		CENSUS: 0	DATE:	04/23/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:50 AM
MET WITH:	Vincent Okorafor and Ogochukwu Okorafor		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Luis De Leon conducted an announced pre-licensing inspection. LPA met with Vincent Okorafor and Ogochukwu Okorafor applicant/administrator. The applicant is applying for a Residential Care Facility for the Elderly to serve residents for the age range from 60 years and over. This is an initial application. The requested capacity is six (6) non-ambulatory residents of which one (1) may be bedridden in any room on first level. A waiver has been granted for hospice care for six (6) residents. Currently, there are no residents residing at the facility. Physical Plant: The physical plant is a two-story family residence located in a residential neighborhood. First floor: There are four (4) residents’ bedrooms (Rooms 2, 3, 4, and 5), bedridden residents can be placed in any of these bedrooms. Bedrooms 1 and 6 on floor plan are designated for activity room and conference/office room. Additionally, the first floor has a kitchen, dining room, living room, reception, and laundry room. There are four (4) full bathrooms, and one (1) half-bathroom. Second floor is not accessible to residents and access to stairs is locked from residents. Second floor: two staff bedrooms and one bathroom. Passageways, walkways and patios are free from obstructions. The entrance and side areas are free of hazards and debris. There is an attached car garage on the facility. Fire clearance: Fire clearance is granted as of 12/26/2025 for five (5) non-ambulatory and one (1) bedridden resident. Each bedroom is equipped with a smoke detector. The facility is equipped with a carbon monoxide detector. Two (2) fire extinguishers are fully charged and last serviced on 06/21/2025. (continued on LIC-809C)

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/23/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BLOOMORA GROVE	FACILITY NUMBER: 198603945
	VISIT DATE: 04/23/2026

NARRATIVE

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Outdoor activity area in backyard: Outdoor activity area is furnished with chairs and tables and in compliance. A shaded area in the backyard at the outdoor activity area is provided.

Facility, Residents & Staff Files: Locked cabinets for records of staff and residents are installed and available in the front office. Licensee will update liability insurance policy to show facility's name and submit a copy of new policy to regional office.

Water Temperature/ Fire extinguishers: Bathrooms are clean and operational. The hot water temperatures were tested in all resident bathrooms and were within the required range of 105-120 degrees F in compliance with Reg Title 22.

Kitchen and phone: The kitchen was inspected, and kitchen appliances were observed to be working properly. Cleaning items will be kept locked in a cabinet inside the laundry closet and under the kitchen sink and inaccessible to residents. Sufficient disposable cups, plates and cutlery were observed. Knives/sharps are secured inaccessible to residents. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Food menus are available for review. Landline telephone and internet are available for residents’ use and operable.

Health Related Services: First Aid Kit was observed and locked cabinets were observed for storing residents’ medication.

Disaster Preparedness: Facility has an emergency disaster plan in place. The facility is prepared with flashlights and emergency lighting for residents to use during power outages.

Bodies of Water: There was no body of water observed on property.

Findings/ Exit: No issue was observed during today’s visit. Exit conference was conducted. LPA conducted Component III orientation to applicants during the pre-licensing visit.

A copy of this report was provided to applicants. LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, s/he has been instructed to communicate with the CAB Analyst who assigned to his/her application.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/23/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026

LIC809 (FAS) - (06/04)

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