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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881635
Report Date: 01/29/2025
Date Signed: 01/29/2025 10:32:35 AM

Document Has Been Signed on 01/29/2025 10:32 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DIGNITY HOME CAREFACILITY NUMBER:
331881635
ADMINISTRATOR/
DIRECTOR:		OKAFOR, TESSYFACILITY TYPE:
735
ADDRESS:15445 LEGENDARY DRIVETELEPHONE:
(818) 277-8831
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 6CENSUS: 0DATE:
01/29/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Tessy Okafor, applicantTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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On January 29, 2025 Licensing Program Analyst (LPA) Seo Jeon made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA met with Tessy Okafor, Applicant, who accompanied LPA for the inspection. The Applicant has submitted an application for six (6) ambulatory residents. On September 24, 2024 the Riverside County Fire Department approved a fire clearance for which the applicant has applied for.

The home is a two story structure consisting of four (4) bedrooms, three (3) bathrooms, kitchen, dining room, family room, garage, and backyard with a covered patio. One (1) bedroom is on the first floor, and three (3) bedrooms are on the second floor. The bedrooms were observed to have bed, lighting, night stand, chest of drawers and area for sitting. There is plenty of extra linen (sheets, blankets, towels) that were observed to be in good repair. The smoke and carbon monoxide detectors were tested and found to be operable.

The hot water temperature was tested and was found to be within regulatory limits measuring at 120 degrees Fahrenheit. The facility is equipped with flashlights, night lights and solar panels. The facility has an emergency disaster plan and infection control training plan on file. The facility has a sufficient supply of dishes, cooking and eating utensils, that were observed to be in good repair. The facility food supply was observed to be sufficient as there was 2-day supply of perishable and a 7-day supply of nonperishable food items. The facility has an emergency food and water supply. There is a fully stocked first aid kit. Resident and staff files will be stored in a locked cabinet in work station area.

Continued on LIC809-C....
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DIGNITY HOME CARE
FACILITY NUMBER: 331881635
VISIT DATE: 01/29/2025
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The passageways, and ramps/inclines are clear and free from obstruction. The home has two (2) fully charged fire extinguishers. The facility does not have any known guns or ammunition stored on grounds. The sharps/knives are stored in a locked cabinet in the kitchen. The medications will be kept in individual boxes that will be stored in a locked cabinet located in the kitchen.

The required postings such as facility sketch, resident council, theft and loss policy, personal rights were posted on the living room wall. The Applicant will obtain PUB475 and Long Term Care Ombudsman poster and post them on the same area with other required posters.

The facility was observed to have activities to encourage socialization such as gardening activities, puzzles, movies, music, and exercise equipment as well as a covered patio with plenty of outdoor space for walking and physical activities.

The applicant successfully completed COMP III orientation on January 28, 2025.

Pre-Licensing is incomplete and the following corrections to be resolved.

Long Term Care Ombudsman poster in correct size.

Complaints hot line poster (PUB475) in correct size.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
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