<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602858
Report Date: 06/04/2024
Date Signed: 06/04/2024 04:14:12 PM

Document Has Been Signed on 06/04/2024 04:14 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:KOKUMAH EVERYDAY GRACE ONE INCORPORATIONFACILITY NUMBER:
198602858
ADMINISTRATOR/
DIRECTOR:		JOHN WILSONFACILITY TYPE:
735
ADDRESS:21236 FIBRE COURTTELEPHONE:
(818) 448-3012
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY: 4CENSUS: 4DATE:
06/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Staff, Oluranti KikiowoTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 6/4/24 using the Compliance and Regulatory Enforcement (CARE) tool. LPA arrived unannounced and met with Staff, Oluranti Kikiowo. The administrator, Olu Odofin, arrived at 2:00 pm to assist with the visit. The facility is licensed for (4) ambulatory adults ages 18 - 59. There are currently 4 clients residing at the home.

LPA inspected the facility and observed the following:
The facility is a single story home consisting of 3 client bedrooms, 1 administrator's office, 2 bathrooms, living room, dining room, kitchen, and a garage. There is no swimming pool on the premises. The backyard has a shaded area for client to use. Smoke and carbon monoxide combo detectors are located in each room. Food supplies are sufficient. There are sufficient number of staff to provide care and supervision in all the shifts. Staff are cleaning and disinfecting during each shift and more often for high touched surfaces. Cleaning supplies are locked in the garage storage cabinet. Knives and sharps are locked in the metal cabinet located in the dining room. Medications are centrally stored and are being administered as prescribed. The emergency disaster plan has been reviewed annually. The disaster drills are conducted monthly.

LPA will return another day to review client and staff files. No deficiencies are being issued today. An exit interview was held and a copy of this report was given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2024
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 1