198603650-7-31-2025-28-AS-BPEA-DK4QPP-20250731122105

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603650
Report Date: 07/31/2025
Date Signed: 07/31/2025 12:21:54 PM

Document Has Been Signed on 07/31/2025 12:21 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:	07/31/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:44 AM
MET WITH:	Evelyn Duromola - Licensee/Administrator Oludayo Edgal - Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA met with Veronica Nosike, Direct Service Professional II (DSP II) and night shift staff Ingrid Licorish, Direct Service Professional II (DSP II) and explained the purpose of the visit. At 10:30am, Licensee/Administrator Evelyn Duromola arrived and assisted LPA with the inspection. At 10:40am, Oludayo Edgal, Administrator arrived to assist also. The facility is licensed to care for (4) Developmentally Disabled Adults, ages 18 through 59, (4) ambulatory only. All clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has an approved Infection Control Plan. Staff are adhering to infection control requirements.

Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood, contains a total of (3) client bedrooms, (2) bathrooms, a sitting room with covered fireplace, living room/activity area, kitchen, dining area, backyard, and attached garage. Currently, there are four (4) clients living in the facility. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area and sitting area. Attached garage was inspected and there is an extra refrigerator/freezer to stock up additional food items. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked in a cabinet and inaccessible to clients. There is a fire extinguisher appeared to be fully charged but Administrator could not provide proof of purchase or last service date. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Hot water supply measured 106.3 deg F in bathroom #1, and 106 deg F in bathroom #2.
Operational Requirements: 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. Surety Bond with bond amount of $2000 is valid and expires on 12/18/2026. Last Fire Drill was conducted on 06/10/2025. The facility has a patio in the backyard with table and chairs for client to utilize the outdoor activity.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 07/31/2025

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Staffing: A total of (11) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. LPA inspected the NOC-shift staff file and the staff has the required the facility planned emergency procedure training.
Personnel Records/Staff Training: Reviewed files for (5) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and expiring on 12/27/2026. Administrator has a valid HIV/AIDS training proof at the time of visit.
Clients Rights-Information: Client personal rights are posted. Facility provides internet services to all clients and have access to the facility phone. No client in the facility required any postural support.
Client Records-Incident Reports: LPA reviewed all (4) client files which are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Incident reports, Client Personal Property and Clients Personal Rights observed.
Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. There are no clients with special diets residing at this facility. LPA observed that pesticides and cleaning supplies are stored in the same cabinet as food and medication.
Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for all clients to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed.
Incidental Medical Services: There are no clients at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.
Emergency Intervention: Not-Applicable.

Deficiency cited and Technical Violation issued. Exit interview, appeals rights and a copy of this report was provided to the Administrator, Oludayo Edgal.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/31/2025 12:21 PM - It Cannot Be Edited

Created By: Bennette Pena On 07/31/2025 at 11:46 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DIGNITY HOME CENTER INC. II	FACILITY NUMBER: 198603650
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(h)

Building and Grounds

(h) Medicines shall be stored as specified in Section 80075(m) and (n) and separately from other items specified in Section 80087(g) above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, the licensee did not comply with the section cited above in that LPA observed pesticides, dry food and medication stored in the same cabinet in the office area which poses/posed a potential health, safety or personal rights risk to clients in care.
	POC Due Date: 07/31/2025
	Plan of Correction
1 2 3 4	Licensee/Administrator removed the pesticides, cleaning supplies and stored in a different location inaccessible to clients. *DEFICIENCY CLEARED DURING THE VISIT.*

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	David Sicairos
NAME OF LICENSING PROGRAM MANAGER:

	Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

LIC809 (FAS) - (06/04)

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