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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609370
Report Date: 03/11/2024
Date Signed: 03/11/2024 09:32:00 PM

Document Has Been Signed on 03/11/2024 09:32 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AGAPE RESIDENTIAL HOMEFACILITY NUMBER:
197609370
ADMINISTRATOR:DAVID KAWOOYAFACILITY TYPE:
735
ADDRESS:8800 JUMILLA AVETELEPHONE:
(747) 224-0635
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 4CENSUS: 4DATE:
03/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:David Kawooya- AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mariana Agban and Raymond Comer conducted an Annual Required visit and inspection of the facility. LPAs met with staff and explained the reason for the visit. Administrator David Kawooya arrived shortly after. At approximately 10: 05 am, with the assistance of staff, LPAs took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are interconnected and battery-operated. There is a carbon monoxide detector that functions properly installed in the hallway between resident rooms. The fire extinguisher is located in the dinning area with purchase date 11/29/23.
Kitchen: The kitchen appliances and fixtures were functional. LPAs found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the hallway cabinets. The laundry area is located adjacent to the kitchen area. LPAs didn't observe any chemicals hazards.
Bedrooms: There were four (4) bedrooms designated for clients' use. All four (4) bedrooms are designated for private use. LPAs inspected two (2) out (4) bedrooms, in use by clients, two (2) out of 4 were properly furnished with appropriate beddings and linens with sufficient lighting.
Bathrooms: There are three (3) bathrooms designated for clients' use. LPAs inspected main bathroom was properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 112.3 degrees Fahrenheit. No cleaning supplies or hazardous items were present in the main bathroom during the inspection. LPAs observed cracked and loose floors in the main bathroom. Administrator was advised to fix the floors as this poses a potential health and safety risk for clients.
Common Areas: These included the living room and dining area. The common areas were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. Resident Files: LPAs conducted a file review of resident records to insure compliance of licensing forms. Staff Files: LPAs also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. Medications: Medication and Medication Records were reviewed for proper documentation.

Exit Interview conducted, citation issued and a copy of the report delivered. Appeal Rights given.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2024
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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Document Has Been Signed on 03/11/2024 09:32 PM - It Cannot Be Edited


Created By: Mariana Agban On 03/11/2024 at 12:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AGAPE RESIDENTIAL HOME

FACILITY NUMBER: 197609370

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed cracked and loose floor tiles in the main bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024


LIC809 (FAS) - (06/04)
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