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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610653
Report Date: 12/04/2024
Date Signed: 12/04/2024 12:35:33 PM

Document Has Been Signed on 12/04/2024 12:35 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:CHRISTIAN ANGELFACILITY NUMBER:
197610653
ADMINISTRATOR/
DIRECTOR:		KAYIIRA, KASIBANTEFACILITY TYPE:
735
ADDRESS:40711 WIMBLEDON COURTTELEPHONE:
(661) 523-5398
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: DATE:
12/04/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Margaret Kayiira and Kasibante KayiiraTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 12/04/2024, Licensing Program Analyst (LPA) Melissa Spaeth conducted an announced Pre-Licensing visit to this facility and met with applicants Margaret Kayiira and Kasibante Kayiira. This is an initial application for an adult residential care facility. A fire clearance dated 07/05/2024 was received for four (4) ambulatory clients. The purpose of today’s visit is to conduct the Comp III presentation and inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6.

The Component III presentation was conducted from 10:00 am until 10:30 am,

Today’s site visit consisted of LPA touring the physical plant inside and outside with the applicants from 10:30 am until 11:00 am. LPA observed the following:

Common areas: LPA observed comfortable seating and a television in the family room.

Kitchen/Dining Area: LPA Spaeth observed the kitchen was functional and obtained the required food supply within the pantry. The knives and resident medications will be locked in a kitchen cabinet. A fire extinguisher and the first aid kit are also located in the kitchen. There is a table and chairs located in the kitchen.

Bathrooms: There are three bathrooms which contained a trash can, hand soap, and paper towels.

Continued on 809-C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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: CHRISTIAN ANGEL
FACILITY NUMBER: 197610653
VISIT DATE: 12/04/2024
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Water Temperature: The water temperature was tested at 11:25 am in a bathroom and was 113.0 Degrees F.

Garage: The garage was locked.

Laundry Room: The laundry room was locked and contained the cleaning solutions and the laundry detergent.

Backyard: Comfortable seating is located in a shaded area and the side gate leading from the backyard to the front yard was not locked.

Staff Room: The room was locked and a locked cabinet will be the storage location for staff and client files.

Client Rooms: The four bedrooms contained a bed, lighting, chair, and closet. Bedroom one is set up for two clients.

Linen Closet - Clean linens are located in the hallway.

Smoke and Carbon Monoxide Detectors: The detectors were tested at 11:00 am and were operable.

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 was conducted with the Licensee. A copy of this report was given

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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