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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530200
Report Date: 07/26/2024
Date Signed: 07/26/2024 11:35:04 AM

Document Has Been Signed on 07/26/2024 11:35 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:HOLYSTIC ARF INCORPORATIONFACILITY NUMBER:
365530200
ADMINISTRATOR/
DIRECTOR:		FAGBUYI, ARIYOFACILITY TYPE:
735
ADDRESS:7 VISTA PALERMOTELEPHONE:
(858) 231-9269
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92532
CAPACITY: 4CENSUS: 0DATE:
07/26/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator/Applicant Emmanuel Oyebobola and Administrator Ariyo FagbuyiTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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On 07/26/2024 at 09:15 AM, Licensing Program Analyst (LPA) Melody Brown conducted an announced visit to the facility for purpose of Prelicensing evaluation. LPA Brown met with Administrator/Applicant Emmanuel Oyebobola and Administrator Ariyo Fagbuyi. An initial application to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Bureau (CAB) on 10/24/2023 for a total capacity of four (4) Ambulatory Adult Clients. Fire clearance was granted on 02/21/2024. LPA Brown observed the following:

Structure:
Facility was a two (2) story house with three (3) client bedrooms, one (1) staff bedroom and four (4) bathroom and living room, dining area, kitchen and a gym. There was an attached two (2) car garage.

Heating/Cooling System:
Central heating and air conditioning system installed with one (1) central panel located in the hallway to
control entire house.

Bedrooms:
Each client bedrooms accommodate any ambulatory client. All client bedrooms were adequately furnished
with bed, chair, closet, appropriate linens, adequate lighting, a lamp and an operable smoke/carbon monoxide alarm.

Bathrooms:
The four (4) client/staff bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. LPA Brown tested the water temperatures in the clients' bathrooms. ***CONTINUED ON LIC 809-C***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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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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: HOLYSTIC ARF INCORPORATION
FACILITY NUMBER: 365530200
VISIT DATE: 07/26/2024
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***CONTINUED FROM LIC 809***
LPA Brown verified water temperature was measured at 109 degrees Fahrenheit.

Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments
were secured in a locked drawer located in the laundry area. There was adequate room for food storage. LPA Brown observed the stove to be operational. One (1) refrigerator and two (2) chest freezers were in working condition. There is sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was in the laundry room. Laundry detergents and cleaning supplies were observed in the laundry room in a locked cabinet. Garage door is locked away and not accessible to clients.

Living/Family room:
There was a living/family room with adequate seating for all clients and a working TV.

Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the hallway of the residence.

Yards/Outside:
Patio furniture for outdoor seating observed. Self-latching handle gate on right side of the house that leads
into the backyard. Swimming pool observed with required fenced and locked with a padlock. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan:
Facility sketch was observed posted in a common area. There was Let-Us-No poster, Personal Rights, House Rules observed.

General items:
One (1) fire extinguisher was charged and located in the hallway. Six (6) smoke detectors and two (2) carbon monoxide detectors were tested and were observed to be in working order. Client records and staff records will be stored in a locked cabinet in the staff room. First Aid kit with required components, and locked area for medication storage was observed. LPA Brown observed a facility phone and was operational ***CONTINUED ON LIC 809-C***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
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: HOLYSTIC ARF INCORPORATION
FACILITY NUMBER: 365530200
VISIT DATE: 07/26/2024
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***CONTINUED FROM LIC 809***
as evidenced by LPA dialing the number. The phone number designated for the facility is 951-263-0799.

There is enough Emergency water supply and the required 72-hour emergency food supply for clients and staffs available at the facility. Component III was completed on this day as well.

Additionally, LPA Brown observed facility having Visitor Sign In/Sign Out Sheet and Client Sign In/Sign Out Sheet, upon entering facility.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of clients in care. Facility appears to be ready for licensure.

An exit interview was conducted, and a copy of this report, LIC809 was discussed and provided to
Applicant/Administrator Emmanuel Oyebobola and Administrator Ariyo Fagbuyi.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC809 (FAS) - (06/04)
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