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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609370
Report Date: 01/06/2025
Date Signed: 01/06/2025 03:46:48 PM

Document Has Been Signed on 01/06/2025 03:46 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AGAPE RESIDENTIAL HOMEFACILITY NUMBER:
197609370
ADMINISTRATOR/
DIRECTOR:
DAVID KAWOOYAFACILITY TYPE:
735
ADDRESS:8800 JUMILLA AVETELEPHONE:
(747) 224-0635
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 4CENSUS: 4DATE:
01/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:11 AM
MET WITH:David Kawooya- AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff and explained the reason for the visit. Administrator David Kawooya was contacted and arrived shortly after. At approximately 10:15 am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors were tested and functioned properly. The fire extinguisher is in the dining area, and the purchase date is 1/06/2025. Kitchen: The kitchen appliances and fixtures were functional. LPA found sufficient perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the hallway cabinets. The laundry area is located adjacent to the kitchen area. LPA didn't observe any chemical hazards.
Bedrooms: There were four (4) bedrooms designated for clients' use. All four (4) bedrooms are designated for private use. LPA inspected (3) out of (4) bedrooms, in use by clients, three (3) out of 4 were properly furnished with appropriate beddings and linens with sufficient lighting.
Bathrooms: There are three (3) bathrooms designated for clients' use. LPA inspected main bathroom was properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 111.5 degrees Fahrenheit. No cleaning supplies or hazardous items were present in the main bathroom during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. Resident Files: LPA conducted a file review of resident records to ensure compliance with licensing forms. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and in compliance with licensing forms. Medications: Medication and Medication Records were reviewed for proper documentation. Cash Resources: LPA with the assistance of the Administrator reviewed cash resources for four residents. Cash logs and receipts were consistent. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit.
Exit Interview Conducted and a Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025
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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