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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610170
Report Date: 11/20/2024
Date Signed: 11/20/2024 06:25:29 PM

Document Has Been Signed on 11/20/2024 06:25 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
WOODLAND HILLS S.ASC, 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:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:54 PM
MET WITH:Adedeji Fagbola - AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:25 PM
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A One (1) Required Annual visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with Administrator Adedeji Fagbola. Purpose of the visit was stated. This is North Los Angeles Regional Center vendored facility level IV-G.

At 3:16 PM, A tour of the physical plant was assessed and the following was noted:

The main door is the only entrance being utilized for entry. Screening area is located upon entrance by the dining area. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted on the walls. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

Facility has four (4) bedrooms and two (2) bathrooms. One (1) bedroom was converted into an office for staff use. The swimming pools was observed to be appropriately fenced.
Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.
Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature measured at a range of 116.6°F to 117.2°F and within the required range.
Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit. (continued to LIC 809-C)

(continued from LIC 809)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EL-SHADDAI'S ARF INCORPORATION
FACILITY NUMBER: 197610170
VISIT DATE: 11/20/2024
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(continued from LIC 809)

Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area was observed to be clean and sanitary. All the toxins, cleaning solutions and disinfectants are locked in the cabinet below the kitchen sink.
Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.
Temperature of facility wall thermostat is set at 74°F and observed to be within the required range.
Fire extinguisher. There is a fire extinguisher in the facility located in the living. Extinguisher was observed to be full and last bought on 11/20/24. Dual smoke/carbon monoxide alarms are hardwired and interconnected, tested and observed to be operable. The garage is also currently being used as frozen and emergency food storage, PPE, décor, and old equipment storage. The garage has no access from the inside only on the front main garage panel. The laundry room is located adjacent to the kitchen, laundry soap and other toxins are kept in a cabinet inside the laundry room and observed to be locked. Dishwashing liquid and other cleaning agents are kept locked in the laundry cabinet.

Medication was observed to be inaccessible and stored in a secured filing cabinet located in the dining area. Medication records and procedures reviewed with staff. There is a complete First Aid kit in the medication cabinet.



Client records were reviewed for current IPP and/or Needs and Service plans. Physician report, admission agreements and P & I fund. Client records appeared to be complete and current. Staff records were checked. Staff present has criminal record clearances and associated to this facility.
Staff records appear to be complete and current.

Disaster drill was last conducted on 11/16/24. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
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