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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 02:27:15 PM

Document Has Been Signed on 01/26/2022 02:27 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Moses Wakabi - AdministratorTIME COMPLETED:
02:00 PM
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LPA conducted an unannounced case management visit to this facility to follow up on the incident occurred on 01/12/2022 wherein Resident #1 (R1) went to the neighbor and destroyed some property. LPA conducted physical plant tour at around 12:45 PM and interviewed the administrator at around 1:15 PM.

During the tour, LPA observed that the fence which was destroyed by R1 is now repaired and was repaired by a contracted repairman of the administrator. LPA interview with the administrator also revealed that this facility is a level 3 vendored facility but R1 had a one on one (1:1) staff from 9:00 AM to 1:00 AM everyday seven (7) days a week. Further interview also revealed that R1 is medication compliant but had this episode every three (3) months or so. Administrator agreed to have R1 re assessed and re evaluated to ensure that R1 is appropriate for this facility. A follow up visit may be done on a later date to follow up on this issue.

There was no health and safety issue observed during this visit.

Exit interview conducted. Copy of this report.
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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