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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609990
Report Date: 04/14/2025
Date Signed: 04/14/2025 03:45:34 PM

Document Has Been Signed on 04/14/2025 03:45 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:AMENA LOVE BOARD AND CAREFACILITY NUMBER:
197609990
ADMINISTRATOR/
DIRECTOR:		JONES, MERCERFACILITY TYPE:
740
ADDRESS:10751 VIKING AVETELEPHONE:
(747) 239-3247
CITY:NORTHRIDGESTATE: CAZIP CODE:
91326
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
04/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:29 AM
MET WITH:MERCER JONES- AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff Carlo Magcalas and explained the reason for the visit. Shortly after, LPA met with Administrator Mercer Jones. At approximately 10:40 am, with the assistance of staff, LPA took a tour of the physical plant, facility temp at 75 degrees. Required postings were observed in the entry area. The smoke alarms and carbon monoxide are properly functional. The fire extinguisher is located in the kitchen with date of purchase 08/22/2024.

Kitchen: The kitchen appliances and fixtures were functional. LPA 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 kitchen cabinets.
Bedrooms: The facility has five (5) bedrooms total. There were four(4) bedrooms designated for residents' use. One(1) bedroom is designated for staff. All bedrooms, in use by residents, were properly furnished with appropriate beddings and linens with sufficient lighting.
Bathrooms: There are five (5) bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Water temperature in the bathrooms measured between 105-109 degrees F. No cleaning supplies were observed in the bathrooms during inspection.
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.The gates at both sides of the home were checked to ensure no locks were installed, and that exits and passageways were clear for emergency evacuation.
(Continue on 809C)
Eva MillerTELEPHONE: (818) 596-4373
Mariana AgbanTELEPHONE: 818-738-4525
DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMENA LOVE BOARD AND CARE
FACILITY NUMBER: 197609990
VISIT DATE: 04/14/2025
NARRATIVE
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Garage/ Laundry Area: The garage is attached to the building. The garage is used as storage. There is also a freezer for additional perishable food items. Entry to the garage from inside the home is located by the kitchen. LPA observed the washer and dryer to be in good repairs. No cleaning supplies or toxin stored in the garage at the time of the visit.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms.

Staff Workstation/Office: There is a staff office located in the living room, where staff records are kept and locked in a filing cabinet.

Staff Files: LPA also conducted a file review of staff records to ensure forms are in compliance. During records review LPA observed S3 has no physical file at the facility. In addition LPA observed that S2 has expired First Aid/CPR certificate. Administrator stated that all required documents will emailed to LPA Agban promptly.



Medications: Medication and Medication Records were review for proper documentation.

Exit interview conducted, citations issued, appeal rights given and copy of this report signed and delivered.
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SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/14/2025 03:45 PM - It Cannot Be Edited


Created By: Mariana Agban On 04/14/2025 at 01:59 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: AMENA LOVE BOARD AND CARE
FACILITY NUMBER: 197609990

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. S2 has expired CPR which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2025
Plan of Correction
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Administrator will email proof of CPR by the POC
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations the licensee did not comply with the section cited above. S3 has no physical file at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2025
Plan of Correction
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Administrator will provide a copy of S3 employee file by the POC date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Eva Miller
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (818) 596-4373
Mariana Agban
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: 818-738-4525
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2025


LIC809 (FAS) - (06/04)
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