198603650-6-11-2024-28-AS-CWOG-D65QF6-20240611120725

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603650
Report Date: 06/11/2024
Date Signed: 06/11/2024 12:08:27 PM

Document Has Been Signed on 06/11/2024 12:08 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/ DIRECTOR:	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: 4	DATE:	06/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	DUROMOLA, ADEBOWALE EVELYN		TIME VISIT/ INSPECTION COMPLETED:	12:30 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 unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with DSP Veronica Nosike who allowed the entry of the facility and explained the reason of the visit. Shortly after, Administrator DUROMOLA, ADEBOWALE EVELYN arrived and assisted LPA with the visit. The facility is approved for serve Developmentally Disabled Adults AGE RANGE 18 THROUGH 59 and ambulatory only. The facility is vendorized as Level 4G Home with San Gabriel Pomona Regional Center. The following twelve (12) tool domains were observed and reviewed: Infection Control, Physical Plant/Environmental Safety, Operational Requirements, Staffing, Personal Records-Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness and Emergency Intervention. 1. Infection Control: The facility has an updated infection control plan in place. The facility staff continues to practice hand washing and disinfected the facility every shift and the facility has sufficient PPE supplies. 2. Physical Plant/Environmental Safety: The facility is a single story house and located in a residential neighborhood area and the facility includes: living room, family room, kitchen, dining area, three client's bedrooms and two clients' bathrooms, staff office and an attached garage. The laundry area is located in the backyard patio. Bedroom#1 has two beds, two drawers, two night stands, required furniture and beddings and sufficient lighting and closet space. Bedroom#2 and #3 has one bed, one night stand, one chair and required furniture and beddings and sufficient lighting and closet space. The two client's bathrooms are clean, sanitary and in a good working condition. The hot water temperature in both bathrooms were tested 110.6 and 116.9 degrees which are within the Title 22 regulation. All the knives and sharp utensils are stored in the file cabinet in the staff office. All the appliances in the kitchen are working properly. All the cleaning supplies and chemicals are stored and locked in the top wall cabinet in the garage. The client's extra personal hygiene products including sanitary pad are stored in the hallway cabinet and staff office. All the extra linen are stored in the hallway cabinet. The hallway light will be on at night time for client to access the non-private bathroom. The facility has a telephone on the premises. LPA inspected the carbon monoxide detectors are working well.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

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
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: 06/11/2024

NARRATIVE

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3. Operational Requirements: The facility is approved for ambulatory clients in the facility. Currently all clients in the facility are ambulatory which is within the fire department requirement. The clients can attend the community events if they have the opportunity or chance. The facility has a patio in the backyard with table and chairs for client to utilize the outdoor activity.

4. Staffing: The facility has sufficient staffing to provide care and supervision to clients. The last fire drill was conducted on 3/8/24. LPA inspected the NOC-shift staff file and the staff has the required the facility planned emergency procedure training.

5. Personal Records-Training: All the staff files are stored and locked in the file cabinet in the staff office. LPA inspected the two staff files and they all have the required documents in their personnel files which included employment application, health screening and TB test result, required training hours and updated First Aid and CPR Certificate. The administrator is DUROMOLA, ADEBOWALE EVELYN and her administrator certificate will be effective through 12/27/24 and she also has the required HIV and TB training certificate in file.

6. Client's Right-Information: No client in the facility required any postural support. The facility does provide at least one internet access device support with video-conferencing for client to meet with their families, primary physician or day program if needed.

7. Food Service: The facility does provide three meals and snacks to clients. LPA inspected the food in the facility and they have sufficient two days perishable and seven days non perishable food supply. All the food in the facility are stored properly. The facility does not have any clients required modified diet that was prescribed by the doctor.

8. Client's Record-Incident Reports: All the clients files are stored in the staff office's file cabinet. All client's files have the required documents included: face sheet, admission agreement, Updated Individual Program Plan (IPP), Updated physician report, TB test result, medication list and ambulatory status. LPA inspected client's P&I record and monies and everything is good.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

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
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: 06/11/2024

NARRATIVE

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9. Health Related Services: The facility would arrange and assist client to medical and dental appointments. All the client's medication are centrally stored and locked in the file cabinet near the kitchen area. LPA inspected all four client's medication and they all seemed accurate and all of them have 30 days supply of medication. LPA inspected the facility first aid kit and they have all the required supplies in the kit.

10. Incidental Medical Services: The facility does not have any client on any restricted health condition plan and no client is currently with any prohibited health condition.

11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610D) and administrator reviewed the plan annually. The facility has two alternative shelter location.

12. Emergency Intervention: The facility does not use any restraint on clients but all staff are trained for CPI and they have the updated CPI training certificate in file.

No deficiencies were observed during the visit.

Exit Interview conducted. A copy of the report was provided to the administrator DUROMOLA, ADEBOWALE EVELYN

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

LIC809 (FAS) - (06/04)

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