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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609370
Report Date: 01/26/2022
Date Signed: 01/26/2022 01:54:44 PM

Document Has Been Signed on 01/26/2022 01:54 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
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: 3DATE:
01/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Moses Wakabi - AdministratorTIME COMPLETED:
12:30 PM
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A Required One (1) year - Infection Control visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with administrator Moses Wakabi. Purpose of visit was stated. LPA observed that only two (2) residents were at the facility during visit. This is a level 3 North Los Angeles Regional Center vendored facility.

A tour of the physical plant was conducted at 10:05 AM and the following was noted:

The main door is the only entrance being utilized for entry. There is a sign on the door that everyone entering at the facility must be screened. Screening area is located immediately upon entrance Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened by the staff upon entry. All staff were observed to be wearing mask.

The facility had submitted and approved Mitigation plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover.

The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

Facility has four (4) bedrooms and three (3) bathrooms. There is an office set up within the living room area. There is no body water in the facility.

(continued to LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2022
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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AGAPE RESIDENTIAL HOME
FACILITY NUMBER: 197609370
VISIT DATE: 01/26/2022
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(continued from LIC 809)

Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.

Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature measured at a range of 116.0°F to 118.4°F and within the required range.

Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit.

Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition. Kitchen area was observed to be clean and sanitary. All the toxins, laundry detergents, cleaning solutions and disinfectants are locked in the kitchen cabinet.

Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.
Temperature of facility wall thermostat is set at 74.0°F and observed to be within the required range.

Fire extinguisher. There is a fire extinguisher in the facility located in the dining area. Extinguisher was observed to be operable and last bought on 08/26/21. Dual Smoke/Carbon Monoxide detectors hardwired and interconnected. All were tested and observed to be operable.

Garage is attached to the house and was locked. Garage is currently being used as PPE, emergency and frozen food storage. Cleaning solutions and laundry detergents are observed kept in the locked cabinet in the garage.

Medication was observed to be inaccessible and stored in a secured cabinet. There is a complete First Aid kit attached to the dining hall wall.

There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
LIC809 (FAS) - (06/04)
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