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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602858
Report Date: 06/06/2024
Date Signed: 06/06/2024 11:04:04 AM

Document Has Been Signed on 06/06/2024 11:04 AM - 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:
06/06/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Staff, Oluranti KikiowoTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) conducted a subsequent visit to continue the annual inspection. LPA met with administrator, Oluwagbemiro Odofin, and explained the reason for the visit. The initial visit was held on 6/4/24.

During the visit today, LPA reviewed 4 Client files. The files have the required documents such as the admission agreement, medical assessment, TB test, consent forms, IPP, and Property Valuable form. LPA also reviewed the clients' P&I ledgers.

LPA reviewed 4 Personnel files. The administrator (Oluwagbemiro Odofin) certificate expires on 7/7/24. His HIV & TB training was completed on 3/22/24. Staff are fingerprint cleared and associated to the facility. Their CPR & First Aid training certificates are current. All staff files contain the required documents.

There are no deficiencies 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: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2024
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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