<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609370
Report Date: 01/26/2024
Date Signed: 01/26/2024 10:23:26 AM

Substantiated


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 HOMEFACILITY NUMBER:
197609370
ADMINISTRATOR:WAKABI, MOSES DFACILITY TYPE:
735
ADDRESS:8800 JUMILLA AVETELEPHONE:
(747) 224-0635
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:4CENSUS: 4DATE:
01/26/2024
UNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Carolyn Alexandra TIME COMPLETED:
10:30 AM
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 visit to the facility to issue an amended report to the above allegation. On 10/18/23, LPA Michael Cava conducted his investigation. Based on the information obtained, the investigation was deemed Unsubstantiated at that time. Since then, a review and additional information was received. This information revealed that prior to the incidents on 09/26/21 and 10/11/21, Resident 1 (R1) already required one to one supervision. R1 is very hyper and regional center was working on getting one on one staff so that they can constantly monitor R1. There were incidents and concerns made by the facility’s neighbors of the noises and yelling from R1. There were also incidents where R1 eloped into the neighborhood, causing damage to the neighbors cars, and getting onto a neighbor’s driveway before getting redirected by staff. Despite R1 never being left alone by staff, who always had to redirect R1, adequate one to one supervision wasn’t approved by Regional Center initiated until 10/15/21. Therefore, based on the new information obtained, the allegation of R1 not being provided adequate supervision is Substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2024
Section Cited
CCR
80078(a)
1
2
3
4
5
6
7
Responsibility for Providing Care and Supervision: (a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement was not met as evidenced by: Information received revealed that R1 required constant
1
2
3
4
5
6
7
No further corrections needed at this time. During the LPA’s visit, it was confirmed that R1 is being provided the one to one supervision.
8
9
10
11
12
13
14
monitoring by staff when admitted into the facility. A need which was not met until Regional Center initiated it on 10/15/21. This poses an immediate health and safety risk to the residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2