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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881203
Report Date: 01/09/2025
Date Signed: 01/09/2025 11:55:37 AM

Document Has Been Signed on 01/09/2025 11:55 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GLORY HOMES ARFFACILITY NUMBER:
361881203
ADMINISTRATOR/
DIRECTOR:		ADEWUMI, PETERFACILITY TYPE:
735
ADDRESS:15168 WISTERIA LANETELEPHONE:
(310) 407-9954
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 4CENSUS: 0DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:41 AM
MET WITH:Administrator, Omotola AdewumiTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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On 01/09/2025 at 9:41AM, Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPA was greeted by a staff and gained access to the home. Licensee Peter Adewumi was contacted and LPA left a voicemail message and stated the purpose of the visit. LPA explained the purpose of the visit to Administrator Omotola Adewumi. LPA observed no clients in care.

The facility is a two (2) story level home and has four (4) bedrooms, 3 and a half (3 1/2) bathrooms, kitchen, dining room, living room, attached three (3) car garage, one (1) shed and backyard. The facility plans to be vendorized by Inland Regional Center (IRC). LPA completed a walk through of the facility, review of staff records, and LPA observed where medications will be kept.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA did not observe any clients during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 112 degrees Fahrenheit. The facility is equipped with operational smoke detectors, a carbon monoxide detector, charged fire extinguishers, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, labor laws, and emergency disaster plan were posted in a common area. Client medications will be kept in secure cabinets in the kitchen inaccessible to clients. LPA observed night light in the hallway leading to clients' shared bathroom. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation on LIC809C ***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GLORY HOMES ARF
FACILITY NUMBER: 361881203
VISIT DATE: 01/09/2025
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Yards/Outside: One shaded patio, two (2) side gates with self-latching handle on the left side of the house that leads into the backyard, attached three (3) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPA Small observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA Small reviewed administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. Client and staff files will be kept in a locked filing cabinet in the dining area. .

No deficiencies were cited during this visit. An exit interview was conducted where this report LIC809 and LIC809C were discussed, and copies were provided to Administrator Omotola Adewumi.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC809 (FAS) - (06/04)
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