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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603658
Report Date: 01/17/2025
Date Signed: 01/17/2025 04:11:14 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/09/2025 and conducted by Evaluator Mayra Cota
COMPLAINT CONTROL NUMBER: 28-AS-20250109190650
FACILITY NAME:DIGNITY HOME CENTER INCFACILITY NUMBER:
198603658
ADMINISTRATOR:DUROMOLA, ADEBOWALE EVELYNFACILITY TYPE:
735
ADDRESS:230 E BENWOOD STTELEPHONE:
(626) 922-3944
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY:6CENSUS: 6DATE:
01/17/2025
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Evelyn Duromola, AdministratorTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Staff did not prevent a substance from being placed in resident's personal item.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Mayra Cota, Nune Margaryan and Luis De Leon, conducted an unannounced complaint visit in response to the above allegation. LPAs met with Evelyn Duromola, Administrator, who assisted with today’s visit.

On today’s visit, LPAs conducted tour of the facility, obtained:client and staff rosters, reviewed Client 1 (C1's) file and obtained copies of Face Sheet, Functional Capability Assessment,Monthly Behavior Charting, Staff notes dated 01/08/2025 and Special Incident Reports (SIRs) dated 01/04/2025, SIR dated 01/06/2025. Copies of 30 Days Behavioral Assessment and Indiviual Program Plan (IPP) will be emailed to LPA Mayra Cota. LPAs connducted interviews with Administrator, Staff 1 - Staff 3 (S1 - S3), Quality Assurance Specialist (QA) from San Gabriel/Pomona Regional Center (SGPRC) and Client 1 (C1) and Client 3 (C3). LPAs attempted to interview Client 2 (C2), Client 4 (C4), Client 5 (C5) and Client 6 (C6).

Continue 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20250109190650
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DIGNITY HOME CENTER INC
FACILITY NUMBER: 198603658
VISIT DATE: 01/17/2025
NARRATIVE
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In regards to the allegation: Staff did not prevent a substance from being placed in resident's personal item. It was alleged that someone in the group home put roach powder in client's face mask. It was also alleged that roach powder was put around the group home

LPAs interviewed Administrator and staff and they denied the allegations and stated that C1 has a history of fabricating stories. Interviewed QA also confirmed that C1 has a history of fabricating stories. At the time of reviewing C1s file, LPAs observed that C1 receives behavioral services where the behavior of false statements and habitual lying are being tracked. Per Administrator and staff interviews, C1s story fabrication is being monitored and documented. During the interview with C1 they did not indicate anything regarding staff putting roach powder in C1s mask. C1 just indicated they had back pain and went to the emergency room due to the pain and was discharged the same day. Per C1s file review, LPAs observed that C1 often makes false statements. Interviewed C3, stated they did not hear anything about this matter.

Interviews and documentation reviewed do not corroborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

Exit interview conducted with Administrator and a copy of this report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2