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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603650
Report Date: 12/21/2023
Date Signed: 12/21/2023 04:02:50 PM

Document Has Been Signed on 12/21/2023 04:02 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. IIFACILITY NUMBER:
198603650
ADMINISTRATOR:DUROMOLA, ADEBOWALE EVELYNFACILITY TYPE:
735
ADDRESS:211 S LARK ELLEN AVETELEPHONE:
(626) 922-3944
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
12/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:32 PM
MET WITH:DUROMOLA, ADEBOWALE EVELYNTIME COMPLETED:
04:00 PM
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On today's date, Licensing Program Analyst (LPA) Wong conducted a Case Management-Incident visit for an incident report received by CCLD on 12/14/23. San Gabriel Pomona Regional Center Service Coordinator Sally Cano faxed the Special Incident Report and SOC 341 to the CCLD office as indicated on reporting requirements.

The incident was reported that Client#1(C1) shared the information to the program manager from Get Safe and reported Client#1 (C1) met up with a guy that met online in October, 2023 and after the incident, C1 was in pain and bleeding and not sure if its consensual or not but C1 has no contact with the person anymore and only met once.

LPA spoke with the administrator and stated all clients in the facility have been received safety training once a week from Get Safe and CBEM. Facility staff also tried to convince and encourage clients not to go out at night time but it's client's personal right. LPA reviewed C1's IPP and indicated that C1 is able to go out without any supervision.

No deficiencies cited during today's visit.

Exit interview conducted with Administrator DUROMOLA, ADEBOWALE EVELYN and a copy of the report was provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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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