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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881266
Report Date: 03/12/2025
Date Signed: 03/12/2025 11:46:32 AM

Document Has Been Signed on 03/12/2025 11:46 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:EMMANUEL'S GROUP HOME ARF, INC.FACILITY NUMBER:
331881266
ADMINISTRATOR/
DIRECTOR:		TAYE O DODO-WILLIAMSFACILITY TYPE:
735
ADDRESS:6 VILLA SCENCEROTELEPHONE:
(818) 993-3666
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92532
CAPACITY: 4CENSUS: 2DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Licensee/Administrator Emmanuel OyebobolaTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 03/12/2025 at 08:30 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPA Brown was greeted by a staff and gained access at the home. Licensee/Administrator Emmanuel Oyebobola was contacted and informed of the visit. LPA Brown explained the purpose of the visit to Licensee/Administrator Oyebobola.

The facility has four (4) bedrooms, two (2) and 1/2 bathrooms, kitchen, dining room, living room, laundry room, attached garage, and a backyard. The facility is vendorized by Inland Regional Center (IRC). LPA Brown completed a walkthrough of the facility, review of records, medications audit and Personal & Incidental (P&I) audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed two (2) clients during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 70 degrees Fahrenheit. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs, and sufficient lighting. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperature tested at 114.2 degrees Fahrenheit. The facility is equipped with operational combined smoke detectors and carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book. However, LPA Brown observed two (2) bottle spray of ants and roach spray under the kitchen sink, not locked and accessible to clients in care. Deficiency will be issued. Moreover, LPA Brown observed two (2) window screens in disrepair. Technical Violation will be issued.

Posters such as; the personal rights, CCLD complaint poster, emergency disaster plan, labor laws and Visitation Policy, and House Rules were posted in a common area. Client medications were kept in secure cabinet inaccessible to clients. *** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: EMMANUEL'S GROUP HOME ARF, INC.
FACILITY NUMBER: 331881266
VISIT DATE: 03/12/2025
NARRATIVE
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LPA Brown observed no night lights at the hallway leading to clients' shared bathroom. Deficiency will be issued. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard, attached three (3) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPA observed more than two (2) day(s) supply of perishable food and more than seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: The facility has an updated Infection Control Plan, Emergency Disaster Plan, Liability insurance and Surety Bond. LPA Brown reviewed two (2) client files for admission agreements, medical assessments/physician reports, Individual Program Plan (IPP) and Centrally Stored Medications List/Physician Orders. LPA Brown observed files reviewed were complete. LPA Brown also reviewed staff and administrator's file for First Aid/CPR certification, Emergency Intervention Certification (CPI), criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA Brown observed no issues, files reviewed were complete.

LPA Brown audited two (2) clients’ medications and no issues were observed. LPA Brown audited two (2) client P&I and no issues observed.

Deficiencies and Technical Violation were issued during this visit. An exit interview was conducted where this report LIC809, LIC809D, LIC9102 and Appeal Rights were discussed, and copies were provided to Licensee/Administrator Emmanuel Oyebobola.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/12/2025 11:46 AM - It Cannot Be Edited


Created By: Melody Brown On 03/12/2025 at 10:24 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: EMMANUEL'S GROUP HOME ARF, INC.
FACILITY NUMBER: 331881266

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not ensuring that the two (2) bottle spray of ants and roach spray under the kitchen sink, were locked and not accessible to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2025
Plan of Correction
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Licensee immediately removed the two (2) bottle spray of ants and roach spray under the kitchen sink and transferred it to a locked cabinet during the facility visit today, 03/12/2025. Plan of Correction (POC) cleared.
Licensee stated to train all staff on CCR 80087(g) and submit proof of staff training log to LPA Brown by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/12/2025 11:46 AM - It Cannot Be Edited


Created By: Melody Brown On 03/12/2025 at 10:24 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: EMMANUEL'S GROUP HOME ARF, INC.
FACILITY NUMBER: 331881266

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview], the licensee did not comply with the section cited above by not ensuring that night lights were maintained in hallways and passages to non-private bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2025
Plan of Correction
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Licensee stated to obtain/purchase night lights and submit proof to LPA Brown by the Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
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