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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603819
Report Date: 02/10/2026
Date Signed: 02/10/2026 03:57:02 PM

Document Has Been Signed on 02/10/2026 03:57 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:KOKUMAH EVERYDAY GRACE TWO INCORPORATIONFACILITY NUMBER:
198603819
ADMINISTRATOR/
DIRECTOR:		ODOFIN,OLUWAGBEMIROFACILITY TYPE:
735
ADDRESS:115 EAST GLADSTONE STREETTELEPHONE:
(818) 448-3012
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 4CENSUS: 3DATE:
02/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:38 PM
MET WITH:Administrator Oluwagbemiro OdofinTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual inspection. LPA was greeted by staff and explained the reason for visit. Administrator Oluwagbemiro Odofin arrived shortly after to assist.

The facility is licensed to serve four (4) ambulatory clients, age range 18-59. All clients receive services from San Gabriel/Pomona Regional Center.

The facility is a single-story home located in Glendora. The home consists of three (3) client bedrooms, one (1) office, three (3) bathrooms, living room, dining room, kitchen, laundry area, front yard, back yard and attached garage.

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

Living room and dining area were observed clean and free of obstruction with sufficient seating. Living room contained a covered fireplace, inaccessible to clients in care. Games and activities were observed available for clients use.

Kitchen was observed clean and free of pests. LPA observed sufficient supply of nonperishable food for one week and perishable foods for a minimum of two days. Soaps, detergents, and cleaning supplies were observed to be stored away from food supplies. Sharps are secured in a locked hall closet.

continued on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KOKUMAH EVERYDAY GRACE TWO INCORPORATION
FACILITY NUMBER: 198603819
VISIT DATE: 02/10/2026
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Centrally stored medications were observed secured in a locked cabinet located in the dining area. The facility uses the Medication Administration Record (MAR) log to document medications given.

Combination smoke/carbon monoxide detectors are located throughout the facility, were tested and are operable. Fire extinguisher located in the kitchen. Emergency drills conducted regularly, last drill completed 11/10/2025.

LPA inspected all client bedrooms and were observed to contain the required bedroom furniture including, for each client, a bed, a chair, a night stand, and a lamp or lights necessary for reading. Linens were observed clean and in good repair. Bathrooms were observed to be clean, water temperature in bathrooms measured at 114.4°F, 112.2°F, and 117.8°F, which within the required 105°F - 120°F.

There are no pools or large bodies of water. There is a covered patio located in the backyard with sufficient seating for clients in care. Passageways and exits are free of obstructions.

Four (4) staff and three (3) client files were reviewed and were observed to contain required documentation.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during today's visit.

Exit interview was held and a copy of the report was provided to Administrator Oluwagbemiro Odofin.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2026
LIC809 (FAS) - (06/04)
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