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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609704
Report Date: 04/27/2023
Date Signed: 04/27/2023 04:23:41 PM

Document Has Been Signed on 04/27/2023 04:23 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:SAFE LAUREL LLCFACILITY NUMBER:
197609704
ADMINISTRATOR:GBOYEGA AKINBOLAFACILITY TYPE:
735
ADDRESS:16300 VINTAGE STTELEPHONE:
(818) 489-1218
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 3DATE:
04/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Gboyega AkinbolaTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst Tihesha Smith made an unannounced case management- Deficiencies visit at 1:45 pm to discuss an excluded employee with Licensee Cheryl Perkins and Administrator Gboyega Akinbola.

LPA met with Administrator and disclosed the purpose of the visit. The Licensee arrived later.
There were two (2) clients in the facility during the visit. and the other client was at a volunteer program.

During complaint visit not related to case management visit LPA Smith observed excluded individual present for their shift. Per discussion with Licensee and Administrator, both individuals expressed they did not have any prior knowledge that staff #1 (S1) was an excluded individual. Per Licensee and administrator they have not received any information from the department regarding S1 being an excluded individual. Due to the need for more information no deficiencies cited at this time.

Exit Interview Conducted / A Copy of the Report Issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
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
Document Has Been Signed on 04/27/2023 04:23 PM - It Cannot Be Edited


Created By: Tihesha Smith On 04/27/2023 at 02:24 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: SAFE LAUREL LLC
FACILITY NUMBER: 197609704

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2023
Section Cited
HSC
1569.58

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(a) The department may prohibit any person from being a licensee, owning a beneficial ownership interest of 10 percent or more in a licensed facility, or being an administrator...
This requirement was not met as evidenced by:
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The excluded individual left during visit. POC cleared during visit.
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Based on Interview and Observation, the licensee failed to prohibit an excluded person from working as an administrator in the facility which poses an immediate safety risk to residents in care.
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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:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023


LIC809 (FAS) - (06/04)
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