197609370-1-30-2023-31-AS-TSMH-CNL327-20230130165127

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609370
Report Date: 01/30/2023
Date Signed: 01/30/2023 04:51:34 PM

Document Has Been Signed on 01/30/2023 04:51 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 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:	01/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Shamim Kabunga, House Manager		TIME COMPLETED:	04:53 PM

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

Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced Annual Required visit to this facility. LPA's temperature taken upon entry. The administrator was contacted and authorized staff to sign.

LPA conducted a tour at 3:15 pm of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

LPA was escorted to the living area which also has office area in the corner of the living room. The living room area observed to have adequate furnishings, sufficient lighting and observed to be clean with adequate seating for residents..

LPA was escorted to kitchen area. The kitchen food supply was observed and sufficient for the four (4) residents. Two (2) days of perishable fruits, vegetables, milk, and eggs observed. The freezer is stocked with meats and frozen vegetables. The kitchen was observed to be clean and sanitary. Laundry washer and dryer in kitchen observed to be in good repair.

There is a supply of canned foods, dried foods, and PPEs in garage. Extra water stored in kitchen near table.

The knives locked in drawer in kitchen and toxins locked in cabinet underneath knifes. Both observed to be inaccessible to residents. Medication and first aid kit stored in hallway closet was observed to be locked and inaccessible to residents.

There are four (4) bedrooms designated for residents. All bedrooms were clean, properly furnished and had sufficient lighting. Linen storage observed to have adequate supply of clean linen and towels. There were three (3) bathrooms designated for residents. Each bathroom has posted “wash your hands”

(Cont to 809C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

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

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: 01/30/2023

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

(Cont from 809)

signs and were clean, properly supplied and had functional fixtures.

The water temperature for each bathroom as follows: Main bathroom: 118.0 Fahrenheit, Bedroom #1 bathroom 120.0 degrees Fahrenheit, and Room #4 bathroom 117.0 degrees Fahrenheit.

Smoke alarms and carbon monoxide detectors were present and function properly. There is one (1) fire extinguisher attached to kitchen wall was observed to charged.

In the backyard, a patio table, umbrella and chairs observed with adequate seating.

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: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2