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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610344
Report Date: 02/15/2023
Date Signed: 02/15/2023 02:13:55 PM

Document Has Been Signed on 02/15/2023 02:13 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:AMEN HOMESFACILITY NUMBER:
197610344
ADMINISTRATOR:AYOARIYO, GEORGEFACILITY TYPE:
735
ADDRESS:3611 TOPAZ LNTELEPHONE:
(310) 753-3777
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: DATE:
02/15/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:AYOARIYO, GEORGE - LicenseeTIME COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Evelin Rios conducted an announced Pre Licensing visit to this facility and met with applicant Licensee Geaorge Ayoariyo. The applicant is "Amen Homes". Fire Clearance dated 12/15/2022 was received for four (4) ambulatory residents.

Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6.

Facility is a two story home. Today's site visit consisted of LPA touring the physical plant inside and outside at 12:15 p.m. and observed the following:

There are four (4) resident bedrooms. Resident bedrooms were observed to be appropriately furnished with a single bed, dresser, side table, chair and lighting. The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television and comfortable adequate seating. Resident and staff records will be stored in a locked closet in an room designated as an office. The laundry room located on the second floor adjacent to the bedrooms was observed to have functional washer and dryer. Medications will be stored in a locked filing cabinet between the dining area and living room. The first aid kit was complete and stored in a filing cabinet. There are three (3) bathrooms in the facility, all bathrooms were clean and had adequate lighting.

The kitchen knives and sharps are stored in a locked closet in the kitchen. Kitchen cleaning supplies will be stored in a locked closet in the kitchen. Appliances in the kitchen appeared to be functional. Laundry detergents, will be kept locked in the laundry room. LPA observed a linen closet in the hallway by the bedrooms to have extra linens. The garage has access from inside the house and was observed to be empty. A locked closet by the living room is being used as storage for tools, PPE, paper towels and other items. Facility appears to be clean and in good repair.
(continued on LIC 809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2023
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMEN HOMES
FACILITY NUMBER: 197610344
VISIT DATE: 02/15/2023
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LPA observed dual smoke/carbon monoxide detectors that are hard wired and interconnected. Smoke detector was tested at 12:39 p.m. and was functioning. The fire extinguisher is located in the kitchen and was observed to be fully charged with purchased date 11/22/2022. Hot water was tested at 12:47 p.m. in the common bathroom down stairs and measured at 115.5°F. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements.

There is appropriate outdoor furniture with shade in the backyard for residents. The backyard is fenced. There is no body of water in the facility. LPA observed a locked shed in the backyard being used as storage. LPA observed one side gate closed with no padlock.

Component III was conducted with the Licensee/administrator and Licensee confirmed understanding of Title 22.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.



Exit interview conducted and copy of this report issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
LIC809 (FAS) - (06/04)
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