198603650-7-6-2023-28-AS-CWOG-CTGRAN-20230706125124

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603650
Report Date: 07/06/2023
Date Signed: 07/06/2023 06:24:30 PM

Document Has Been Signed on 07/06/2023 06:24 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	DIGNITY HOME CENTER INC. II		FACILITY NUMBER:	198603650
ADMINISTRATOR:	DUROMOLA, ADEBOWALE EVELYN		FACILITY TYPE:	735
ADDRESS:	211 S LARK ELLEN AVE		TELEPHONE:	(626) 922-3944
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY: 4		CENSUS: 3	DATE:	07/06/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Adebowale Evelyn Duromota		TIME COMPLETED:	01:10 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 Analyst (LPA), Christine Wong, conducted an announced visit to the facility for purpose of a prelicensing evaluation and met with Administrator/Licensee Adebowale Evelyn Duromota. An application was submitted to CCLD on 01/12/2023 for Change of Ownership for a Developmentally Disabled Adults for age range 18 through 59. The requested capacity is for 4 ambulatory only clients. During today's visit, LPA Wong utilized the Compliance and Regulatory Enforcement (CARE) tools for the pre-licensing visit today : 1. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes living room, den, dining area, kitchen, office, three clients bedrooms, two bathrooms and an attached garage. The client bedrooms are spacious and will easily accommodate the client's furnishings. The passageways, walkways, driveways and patios are free from obstructions. There shall be no more than two clients per bedroom. The 1st and 2nd client bedroom has one bed, one chair, one drawer, night stand, required beddings and furniture and sufficient lighting and closet space. The 3rd bedroom has two beds, two night stands, two chairs, two drawers, required beddings and furniture and sufficient lighting and closet space. All bathrooms are clean and sanitary and have a working toilet, bath-tub/shower. Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in hallway cabinet next to the bathroom. The facility also has ample supply of personal hygiene products and stored in the hallway cabinet next to the bathroom. The oven, microwave, washer, and dryer are all working probably. All the cleaning supplies are locked in the cabinet in the garage which inaccessible for clients to use. The hot water temperature in both clients' bathrooms were tested between 111.7 and 112.6 degrees F. The medication are centrally stored and locked in the file cabinet next to the kitchen. The facility has a land-line telephone system. The facility would turn on the hallway night at night and the facility also has flash light for emergency use.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DIGNITY HOME CENTER INC. II	FACILITY NUMBER: 198603650
	VISIT DATE: 07/06/2023

NARRATIVE

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2. Operational Requirements: The facility Fire Clearance was approved on 02/15/23 with 4 ambulatory clients only. The smoke detectors and carbon monoxide detectors are located in the common area and each client rooms and they are all working well. All the facility Posted & readily available for review on the wall near the entrance and the weekly menu is posted next to the kitchen cabinet near the oven. Applicant will be handling cash resources of clients and has a surety bond for $3000, cash resources will be locked and stored with P & I Ledger in the lock box in the office, accessible to designated staff only. The facility has a shaded area in the back yard with tables and sufficient chairs for client to utilize. The facility has board games, books, and other recreational materials for the client's use and placed in the living room area and commensurate with the plan of operation.

3.Personnel Records-Training: All staff files are stored in the file cabinet in the office. The facility administrator will have a designated staff to cover when the administrator is absent. The form of LIC308 was completed.

4.Client Records-Incident Reports: All clients files are stored in the file cabinet in the office. The client register is posted on the wall near the entrance.

5. Client's Rights-Information: The facility will ensure each client has their personal right to be accorded safe, healthful and comfortable accommodations.

6.Food Service: The facility refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. Dishes, cups and flat ware are stored in the kitchen cabinet inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored and locked in the file cabinet in the office. All the cleaning supplies are stored and separated from the food supplies.

7. Health Related Service: The medication will be centrally stored and locked in the facility file cabinet near the kitchen. A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in staff office file cabinet and available for staff use but inaccessible to clients.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DIGNITY HOME CENTER INC. II	FACILITY NUMBER: 198603650
	VISIT DATE: 07/06/2023

NARRATIVE

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8. Disaster Preparedness: The facility has an updated emergency disaster plan dated on 3/24/23 posted on the wall near the entrance and has at least two alternative temporary shelter location.

Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

During the prelicensing inspection, there's one item was observed which do not comply with applicable laws and regulations; the following items must be corrected and proof of correction shall be submitted to the CCLD office to the attention of LPA by 07/14/23. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

1. Stove top is not working and licensee scheduled to be fixed on next Thursday 07/13/23. Even it's not working at the present time but they do have a temporary table top cooker.

An exit interview was conducted and a copy of this report has been furnished to the applicant. 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.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC809 (FAS) - (06/04)

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