198603658-8-18-2023-28-AS-BTAO-CUTPLL-20230818112456

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603658
Report Date: 08/18/2023
Date Signed: 08/18/2023 11:25:08 AM

Document Has Been Signed on 08/18/2023 11:25 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	DIGNITY HOME CENTER INC		FACILITY NUMBER:	198603658
ADMINISTRATOR:	DUROMOLA, ADEBOWALE EVELYN		FACILITY TYPE:	735
ADDRESS:	230 E BENWOOD ST		TELEPHONE:	(626) 922-3944
CITY:	COVINA	STATE: CA	ZIP CODE:	91722
CAPACITY: 6		CENSUS: 6	DATE:	08/18/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Adebowale Evelyn Duromola, applicant		TIME COMPLETED:	11:30 AM

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) Tao conducted an announced pre-licensing inspection. Applicant is applying for Adult Residential Facility to serve clients for age range from 18 years old through 59 years old. This is a change of ownership. The facility is currently licensed as Dignity Home Center, facility # 197802664. LPA met with Adebowale Evelyn Duromola, applicant/ administrator. The requested capacity is six (6). Six (6) clients reside at the facility and all clients were at their day programs at the time of visit. Facility receives case management services provided by San Gabriel Pomona Regional Center. Fire clearance is granted for six (6) ambulatory clients on 02/06/23. Structure: The property is a single-family residence located in a residential neighborhood and consist of four (4) client bedrooms, two (2) bathrooms, living room, kitchen with dining area, office, and laundry area in the attached garage. Passageways, walkways and patios are free from obstructions. The entrance and side areas are free of hazards and debris. Garage is not accessible to clients. Facility had no pool or bodily of water. Bedrooms and Bathrooms for Clients: Bedrooms are spacious, accommodated for clients and in compliance with regulation. Bathrooms have grab bars maintained for each toilet, bathtub and shower. Linens & Hygiene Supplies: Sufficient linen/supplies which include pillowcases, mattress pads, blanket and bedspreads are available. Adequate supply of linen, wash clothes and towels are observed. (- Continued LIC 809 C -)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DIGNITY HOME CENTER INC	FACILITY NUMBER: 198603658
	VISIT DATE: 08/18/2023

NARRATIVE

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Food Service:
Facility had the required food wares stored in the kitchen cupboards and kitchen appliances in place which were inspected and in good repair. Food supply consist of two days of perishable and two weeks of non-perishable was observed.

Smoke Detectors:
Dual smoke /carbon monoxide detectors are tested and operable which are located in hallways and each bedroom.

Toxins:
Poisons, toxins, and cleaning supplies are locked and inaccessible to clients. They are stored separately from food source.

Emergency Phone Numbers, Exit Plan, Signages and posters:
Emergency Disaster Plan and Labor law poster are posted. Exit Plan are available for review.

Outdoor activity area in backyard:
Outdoor activity area is furnished with chairs and table and in compliance. Shaded area in the backyard at the outdoor activity area is provided.

Clients & Staff Files:
Locked cabinets for records of staff and clients are installed and available. Clients file are observed. Applicant will handle cash resources for clients.

Water Temperature:
Water was measured at 115.6 degrees Fahrenheit which was in compliance with Reg Title 22.
(-Continued LIC 809 C -)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DIGNITY HOME CENTER INC	FACILITY NUMBER: 198603658
	VISIT DATE: 08/18/2023

NARRATIVE

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Menu and phone:
Menus are available for review. Free landline telephone is available for clients’ use and operable.

Fire extinguishers:
Fire extinguisher was fully charged which was mounted on the kitchen wall.

Finding:
No issue was observed during today’s visit.

Exit:
Exit conference was conducted with Adebowale Evelyn Duromola, applicant. Applicant requested to waive Component III orientation during this visit since applicant had done Component III orientations a few times from applicant’s other licensed facilities during pre-licensing visits.

A copy of this report was provided to applicant. 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, s/he has been instructed to communicate with the CAB Analyst who assigned to his/her application.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC809 (FAS) - (06/04)

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