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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881203
Report Date: 10/04/2021
Date Signed: 10/04/2021 09:52:26 AM

Document Has Been Signed on 10/04/2021 09:52 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GLORY HOMES ARFFACILITY NUMBER:
361881203
ADMINISTRATOR:ADEWUMI, PETERFACILITY TYPE:
735
ADDRESS:15168 WISTERIA LANETELEPHONE:
(310) 407-9954
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 4CENSUS: 0DATE:
10/04/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Peter Adewumi, licensee/AdministratorTIME COMPLETED:
10:00 AM
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On 10/4/21 Licensing Program Analyst (LPA) Shaunte Henry conducted an announced visit for the purpose of conducting a pre-licensing inspection. Upon arrival the LPA met with Peter Adewumi who assisted with the inspection. The facility is two stories and has 4 bedrooms (3 resident bedrooms and 1 live in staff bedroom), 3 bathroom, a living room, family room, kitchen with dining area, laundry room. On 8/30/21 Victorville Fire Prevention conducted and approved the fire safety inspection for 4 ambulatory clients.

All client bedrooms are furnished with a bed, night stand, dresser, chair, adequate lighting for clients’ use, and emergency lighting. The facility has a sufficient supply of linen for the clients' use. The water temperature appeared to be within 107 degrees Fahrenheit. The smoke and carbon monoxide alarms were tested and are operable. Fire extinguishers are present in the facility and fully charged. The hallways were equipped with night lights. The kitchen was observed to have dishes, silverware, pots, and pans. Knives/sharps are inaccessible. Staff, client files and medication will be locked inaccessible to clients. A COVID-19 screening area and first aid kit was observed. The chemicals will be locked and kept inaccessible to clients. There are no bodies of water on the property. The phone number designated for the facility is (760) 780-1916. The emergency exits are free of obstruction.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22, Division 6, to ensure the health and safety of clients in care. Component III was conducted immediately after the inspection. The facility appears to be ready for licensing.

An exit interview was conducted, and a copy of this report was provided to Peter Adewumi.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Shaunte Henry
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2021
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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