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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881203
Report Date: 11/21/2023
Date Signed: 11/21/2023 11:49:55 AM

Document Has Been Signed on 11/21/2023 11:49 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
SAN BERNARDINO, 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:
11/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Peter Adewumi-LicenseeTIME COMPLETED:
11:55 AM
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On 11/21/23 at 09:32 AM, Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a required Annual visit. LPA introduced self and stated the purpose of the visit to DSP, Omotola Adewumi. LPA observed that there are no clients admitted to the facility. LPA toured the facility with DSP.

The facility has 4 bedrooms, 3 bathrooms, a kitchen, dining area, living room, family room, laundry room, attached garage, and backyard. The facility is pending vendorization by Inland Regional Center. LPA conducted a general overall inspection, which included, but was not limited to, the following:

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 73 degrees Fahrenheit temperature. LPA inspected clients bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. An adequate supply of linens stored in each bedroom. LPA inspected clients bathrooms; bathrooms were clean and appliances were operating appropriately. LPA tested the water temperature in the kitchen faucet, which tested within regulation at 116.6 degrees Fahrenheit. The facility is equipped with operational phone, fire extinguishers, smoke detectors and carbon monoxide alarms. Posters such as; the personal rights, the CCL complaint poster, and emergency disaster plans were posted in a common area. LPA observed the emergency disaster plan outdated since 06/12/21. Technical violation issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for client/staff files, first aid kit and medication. There are no pools, bodies of water, firearms or ammunition. Overall, the facility is clean, in good repair, and operating in safe conditions for future clients in care.

Yards/Outside: One shed, shaded patio, furniture for outdoor seating observed. Side gate on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GLORY HOMES ARF
FACILITY NUMBER: 361881203
VISIT DATE: 11/21/2023
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Food Service: Non-perishable and perishable food supply is sufficient for future clients in care. Dishes, cups, and utensils were also stored properly.

Record Review: LPA reviewed the Licensee's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed an incomplete licensee's file. Technical violation issued. LPA observed an Infection Control not updated/reviewed annually. Technical violation issued.

No deficiencies and technical violations were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C and LIC9201TV were discussed and copies were provided to Licensee, Peter Adewumi who later arrived.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC809 (FAS) - (06/04)
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