197609370-10-18-2023-31-AS-EMIR-D2P2V9-20240221164331

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609370
Report Date: 10/18/2023
Date Signed: 10/18/2023 01:46:16 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/12/2021 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20211012123120

FACILITY NAME:	AGAPE RESIDENTIAL HOME		FACILITY NUMBER:	197609370
ADMINISTRATOR:	WAKABI, MOSES D		FACILITY TYPE:	735
ADDRESS:	8800 JUMILLA AVE		TELEPHONE:	(747) 224-0635
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	4	CENSUS: 4	DATE:	10/18/2023
		UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	David Kawooya		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not providing adequate supervision.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Michael Cava, conducted a subsequent complaint visit to the facility to conclude the investigation regarding the above allegation. It was reported that due to lack of supervision from facility staff, staff are preventing Resident 1 (R1) from banging on the neighbor's garage door and kicking the neighbor's vehicles. The initial visit to this complaint was made by Licensing Program Analyst (LPA) Angelica Arambulo. Today's investigation consisted of interviews with the administrator, two (2) of two staff, R1, a record review, and a physical plant inspection to insure the health and safety of the residents.

Interviews made with the administrator reveal that R1 can be aggressive. There was an incident that occurred on 10/11/21 reporting that R1 had become aggressive towards staff, got out of the home, and kicked neighbors vehicles. It was also revealed during that incident that staff did follow R1 and redirected R1 back into the home. Additional incident reports were reviewed and it revealed that R1 yelled at a nieghbor on 09/26/21 and caused a noise disturbance on 08/17/21, resulting in a visit from Law Enforcement.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 31-AS-20211012123120

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AGAPE RESIDENTIAL HOME	FACILITY NUMBER: 197609370
	VISIT DATE: 10/18/2023

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
26
27
28
29
30
31
32

Both incidents also indicated that staff intervened and had to redirect R1. No arrests or citations reported during the incident on 08/17/21.

Interviews with the administrator and staff also reveal that R1 is never left alone and when R1 goes out, staff follows, accompanies and/or redirects the resident. Interviews also reveal that staff was with R1 on the day of the incident of 10/11/21, when R1 went up to a neighbor's driveway, but R1 did not reach out to hit, nor hurt the neighbor. In addition staff stated that R1 never injured anyone or has ever attempted to hit anyone.

In addition to interviews, LPA had a chance to sit, observe and interview R1. R1 did not show any aggression during the visit. R1 was observed to be having breakfast. R1 also confirms staff is present with them at all times. LPA observed staff presence with R1 at all times during the visit.

Although there was evidence to reveal that on or around 10/11/21, R1 had gone out to kick the neighboring vehicles, and additional incidents on 08/17/21 and 09/26/21, reported of R1's aggressive behavior, there was also supportive information that R1 was not left alone. R1 was being accompanied and redirected by staff during these incidents. Furthermore, R1 did not show any aggression during the LPA's investigation on 10/18/23, and staff was present to provide the care and supervision that R1 requires. Based on the information obtained, there was insufficient information to corroborate the allegation of staff not providing adequate supervision towards R1. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2