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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881302
Report Date: 06/21/2022
Date Signed: 06/21/2022 11:25:36 AM

Document Has Been Signed on 06/21/2022 11:25 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:PASSIONATE HOME 1FACILITY NUMBER:
331881302
ADMINISTRATOR:FADIPE, SUNDAY D.FACILITY TYPE:
735
ADDRESS:29340 GRAND SLAMTELEPHONE:
(347) 698-9678
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 4CENSUS: 0DATE:
06/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Sunday Fadipe - Administrator TIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Ryan Gardner conducted an announced visit to complete a pre-licensing inspection and review component III. LPA Gardner met with Licensee Olajumoke Ijabadenuyi and Administrator Sunday Fadipe. The facility application is for an Adult Residential Facility for four (4) ambulatory clients.

LPA Gardner toured the four (4) bedroom, three (3) bath facility inside and out. Overall, the facility is clean and of newer construction. There no pools, bodies of water, firearms and or ammunition. LPA Gardner observed all bedrooms to be appropriately furnished and have adequate lighting. The three (3) bathroom showers and or bathtubs all have non-skid mats. The hot water temperature was measured in the client’s bathroom at 114.2 degrees Fahrenheit. LPA Gardner observed food storage and preparation areas to be clean and sanitary. Refrigerator and freezer temperatures are maintained at appropriate temperatures. All appliances are clean and operating properly. There is a sufficient supply of linens, towels, and personal hygiene items. The first aid kit was reviewed; all items are present including a First Aid Manuel. LPA Gardner observed an adequate supply of recreation and leisure items and activities. The backyard is completely enclosed with functioning gate to exit to front yard. The outdoor space is suitable for client use that includes a covered patio with a table and chairs. LPA Gardner observed the fire extinguishers to be completely charged. The smoke alarms and carbon monoxide detectors are present and functional. The medications are centrally stored and secured in a locked cabinet. All hazardous materials such as, cleaning and disinfecting supplies, knives and other sharps are locked and inaccessible to clients. All required forms and posters are posted in a common area.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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: PASSIONATE HOME 1
FACILITY NUMBER: 331881302
VISIT DATE: 06/21/2022
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Based on observations made today, the pre-licensing inspection is complete and has no deficiencies.

An exit interview was conducted where this report was discussed and provided to Administrator Sunday Fadipe.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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