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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610170
Report Date: 05/15/2024
Date Signed: 05/15/2024 04:25:05 PM

Document Has Been Signed on 05/15/2024 04:25 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:EL-SHADDAI'S ARF INCORPORATIONFACILITY NUMBER:
197610170
ADMINISTRATOR/
DIRECTOR:		ADEDEJI FAGBOLAFACILITY TYPE:
735
ADDRESS:18927 CHASE STREETTELEPHONE:
(818) 993-3666
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 4CENSUS: 4DATE:
05/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:ADEDEJI FAGBOLA- AdminstratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced CASE MANAGEMENT-INCIDENT visit to this facility and met with Administrator, Adedeji Fagbola. On April 25, 2024, Community Care Licensing (CCL) received a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) from facility Administrator Adedeji Fagbola. On 02/19/2024 facility Administrator was informed from R and D transportation which is responsible for transporting clients from the facility to the day program that Staff 1 (S1) has raised her/his hand towards Client 1 (C1) while C1 was heading towards the van. Administrator had spoken with S1 about the incident. S1 stated that they were trying to prevent C1 going under the rain by taking one client at the time to the van. S1 has told C1 to wait while C2 is taken to the van. During today's visit interviews were conducted with facility Administrator and C1's Case Manager and Staff 3(S3). LPA was informed that S1 was placed under suspension. Administrator provided proof of staff training conducted by the Behaviorist on 02/29/2024.

No deficiencies are cited during today's visit.

Exit Interview Conducted / A Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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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