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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603811
Report Date: 04/29/2025
Date Signed: 04/29/2025 02:00:01 PM

Document Has Been Signed on 04/29/2025 02:00 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ABUNDANT GRACE HOME LLCFACILITY NUMBER:
198603811
ADMINISTRATOR/
DIRECTOR:		OSIBOGUN, OLAIDEFACILITY TYPE:
735
ADDRESS:4640 NORA AVETELEPHONE:
(626) 430-6804
CITY:IRWINDALESTATE: CAZIP CODE:
91706
CAPACITY: 4CENSUS: 0DATE:
04/29/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Olaide OsibogunTIME VISIT/
INSPECTION COMPLETED:
02:00 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 Analysts (LPAs) Nune Margaryan and Blanca Gonzalez conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. LPAs met with Licensee Olaide Osibogun who assist with the visit. An application was received on 09/13/24, for Initial License # 198603811 Adult Resident Facility to serve 4 ambulatory clients in the age range of 18 through 59. There are currently no individuals residing at the facility. LPAs used the inspection tool and the pre-licensing checklist for ARF during this visit. The facility is a one-story house located in a residential area which consist of a living room, dining area, kitchen, 4 bedrooms (one is master bedroom), 2 bathrooms (one is master bathroom). There is a detached garage at the front of facility and office attached to the garage with separate entrance. Facility has a washer and dryer that are fully operational located in the hallway. Dining area has a table and sufficient seating. Living room is fully furnished for client use. There is also fireplace that has a covering that makes it inaccessible to clients. The garage will be used as storage. The client bedrooms are spacious and will easily accommodate the client's furnishings. Passageways, walkways, driveway are free of obstructions. Front, back and side areas are free of hazards. There is a shade area set up in the backyard to accommodate (4) clients. The home does not have a pool or any large bodies of water. Bedrooms have all the required furniture such as beds, chairs, dressers, drawers, nightstands. Window screens are in good repair and windows/curtains/blinds are in good repair and operate properly. Bathrooms have working toilets, wash basins, stand up shower. Master bathroom has a jacuzzi and the other bathroom has a bathtub. Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket. Extra beddings observed in the closet located in hallway. Fire Extinguisher is observed in the dining area fully charged.

Continue 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2025
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 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ABUNDANT GRACE HOME LLC
FACILITY NUMBER: 198603811
VISIT DATE: 04/29/2025
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
26
27
28
29
30
31
32
Telephone system is a land line operable and located in the kitchen. Facility has internet access. Dishes, cups and flat ware are stored in the kitchen, inspected and in good repair. Knives, cutlery and the sharp kitchen utensils are stored in a locked metal cabinet located in the dining area. No food supply observed in the kitchen. Two-day supply of perishables and seven-day supply of non-perishable will be stocked upon the first admission. Kitchen appliances are clean and functioning properly. Smoke/carbon monoxide detectors were observed in common areas and in each client’s bedroom. Chemicals observed locked in the hallway closet. The water temperate was tested and measured within the required 105-120 degrees. Medications along with files will be locked in a file cabinet in dining area. No records were reviewed since the home has never been licensed. A first aid kit has been inspected. It contains all the required supplies along with the current first aid manual. Applicant will be handling cash resources of clients. Cash resources will be locked and stored in the office with P & I Ledger, accessible to designated staff. Fire Clearance was approved on 12/11/24.

Component III is waved: Licensee is currently operating facility of the same category.

The Pre-licensing is complete, and the facility has no deficiencies.

Exit interview conducted and a copy of this report was provided to Licensee. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3