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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880762
Report Date: 06/24/2026
Date Signed: 06/24/2026 02:13:40 PM

Document Has Been Signed on 06/24/2026 02:13 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GLORY HOMESFACILITY NUMBER:
361880762
ADMINISTRATOR/
DIRECTOR:		ADEWUMI, OMOTOLAFACILITY TYPE:
740
ADDRESS:15045 BRUCITE ROADTELEPHONE:
(760) 867-3267
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 6CENSUS: 5DATE:
06/24/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Administrator, Omotola AdewumiTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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On 06/24/2026 at 9:40AM Licensing Program Analysts (LPAs) Renese Howell-Small and Edith Conchas arrived unannounced to conduct the required annual visit to the facility. LPAs met with Administrators Peter Adewumi and Omotola Adewumi and stated purpose of the visit. LPAs observed five (5) residents in care.

The facility has 3 resident bedrooms, 2.5 resident bathrooms, office, kitchen, dining area, living room, laundry room, attached garage, and backyard. LPAs completed a walk through of facility and review of records.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPAs inspected resident bedrooms; they are equipped with the required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPAs inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 105.6 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher and first aid kit. Posters such as; the personal rights, ombudsman and emergency disaster plans were posted in a common area. LPAs also observed cleaning supplies, toxins, sharps, and other dangerous items locked in cabinets made inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed secured and inaccessible to residents. There are no guns or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly.
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Renese Howell-Small
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2026
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GLORY HOMES
FACILITY NUMBER: 361880762
VISIT DATE: 06/24/2026
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Yards/Outside: One shaded patio, a side gate with self-latching handle on the right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the Department.

Record Review: LPAs reviewed five (5) resident files for admission agreements, updated physician reports, and needs and services plans. LPAs observed four (4) out of five (5) resident Reappraisals were not current. A Technical Violation was given. LPAs also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPAs observed staff trainings did not include the required information such as the trainer's name. Technical Assistance was provided. LPA audited three (3) residents medications and observed that there were discrepancies in documentation with Resident 2 (R2) and Resident 5 (R5). A deficiency was cited.

During this visit, deficiencies were cited and technical assistance was given. Technical assistance provides assistance and/or best practices to maintain compliance. Technical violations were also issued, which are violations of the Health and Safety Code (HSC), regulations (CCR), or interim licensing standards (ILS) that do not pose a health, safety or personal rights risk.

LPAs two residents(R1 and R5) had half bedrails. A deficiency was cited.

Administrator stated that to provide the necessary documentation regarding half bed rail to remain in compliance. During the visit, the Administrator was unable to locate the documentation.

An exit interview was conducted where this report LIC809, LIC809C, LIC809D and LIC9102 and Appeal Rights were discussed and copies were provided to the Licensee/Administrators, Omotola Adewumi and Peter Adewumi who arrived later during the visit.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Renese Howell-Small
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/24/2026 02:13 PM - It Cannot Be Edited


Created By: Renese Howell-Small On 06/24/2026 at 01:30 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GLORY HOMES
FACILITY NUMBER: 361880762

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not ensuring that the medication Loratabine for Resident 2 (R2) was administered according to the physician's order, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2026
Plan of Correction
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The Administrator will submit a current physician's order for the medication above to LPA by Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review), the licensee did not comply with the section cited above by not ensuring the facility had the required documentation for the half bed rails for Resident 5 (R5) and Resident 1 (R1) and full bed rails for Resident 2 (R2) and Resident 4 (R4) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2026
Plan of Correction
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The Administrator will contact the physician and obtain the required documentation and submit proof to LPA by Plan of Correction (POC) due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Renese Howell-Small
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2026


LIC809 (FAS) - (06/04)
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