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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610170
Report Date: 12/01/2023
Date Signed: 12/01/2023 11:49:59 AM

Document Has Been Signed on 12/01/2023 11:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:EL-SHADDAI'S ARF INCORPORATIONFACILITY NUMBER:
197610170
ADMINISTRATOR:ADEDEJI FAGBOLAFACILITY TYPE:
735
ADDRESS:18927 CHASE STREETTELEPHONE:
(818) 993-3666
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 4CENSUS: 4DATE:
12/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Adedeji FagolaTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Gina Saucedo conducted an unannounced Annual visit to this facility at 09:20am. LPA Saucedo was greeted by the administrator. The purpose of the visit was discussed, and the client and staff rosters were obtained.

LPA conducted a tour of the physical plant at 09:40 am. By the entrance of the facility there is signs displaying hand washing, coughing etiquette, physical distancing, administrator license certificate, disaster plan. The trash bin in the kitchen area was observed to be with cover/lid.



Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have supply of clean linen and towels in hallway cabinets. Facility has total of four (4) bedrooms: Three (3) for clients: one bedroom is a shared bedroom with a private bathroom. The other two bedrooms are used individually. There is an office for staff which is located next to bedroom three and there is another bathroom located in hallway between bedroom two (2) and bedroom three (3). The bathrooms were observed to be clean with necessary supplies. Hot water temperature for both bathrooms was 118.9 Fahrenheit.

Kitchen area was observed to be clean. LPA reviewed the food service area, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the four (4) clients currently residing there. There is an excess of perishables in several of the cabinets. Sharps observed to be stored, locked, and secured with a key boxed in bottom kitchen cabinet to the right of refrigerator observed to be inaccessible to clients. The fire extinguisher is located in the kitchen area and is fully charged, reading December 2023. The first aid kit and manual are next to the fire extinguisher in the kitchen area against the wall on your left-hand side.



LIC 809-C continued
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2023
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EL-SHADDAI'S ARF INCORPORATION
FACILITY NUMBER: 197610170
VISIT DATE: 12/01/2023
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Living and dining room furniture is accessible for four clients. There is a television and enough seating for four clients. There is internet accessibility and two phones available for client use. Furniture was observed to be in good condition and the fireplace has a covering around it.

Temperature of facility wall thermostat is observed and set to 72 degrees Fahrenheit.



Laundry room is accessible through kitchen leading to the backyard both washer and dryer observed.

Medications are located in dining room locked in a metal/drawer cabinet. Medication storage observed to be locked and inaccessible to clients. There are smoke alarms and carbon monoxide detectors were present and function properly (tested).

Garage is detached from house: used to store excess PPEs, extra water and extra beds. There is also another refrigerator located in the garage area with extra food.

All the toxins, cleaning solutions and disinfectants are stored in three (3) cabinets in laundry room area. Toxin cabinets observed to be locked and inaccessible to clients.

Backyard: There is a large patio table set with umbrella and chairs for clients use. There is pool in the backyard that is locked and secured with a lock and has a fence around it.

Administrative: LPA had the Infection Control emailed to her. The Annual fee is current.

There is additional signs in the kitchen area displaying the Rights of the Individuals, YES postage, Personal Rights, Designation of Administration, Facility sketch/Exit areas, Medical/Health Services, is located against the wall next to the medication cabinet.


An exit interview was conducted, no citation issued, and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC809 (FAS) - (06/04)
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