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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530080
Report Date: 03/15/2023
Date Signed: 03/17/2023 10:15:54 AM


Document Has Been Signed on 03/17/2023 10:15 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/17/2023 09:43 AM

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

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Licensing Program Analysts, Amber Coleman (LPA Coleman) and Michelle Echeverria (LPA Echeverria) arrived at the Glory Homes 2 Residential Care Facility for the Elderly to conduct a Pre-Licensing Visit. LPA's were greeted by Omotola and Peter Adewumi and invited inside. LPA signed in and had temperature taken. LPA's observed COVID station upon entry. Station included PPE, hand sanitizer and paper supplies made available to guests upon entry. LPA's were provided space for LPA's to work and provided a walk through of the facility.

Structure: Facility is a one story residence with 4 bedrooms and 3 bathrooms, dining room, living room, laundry room, kitchen and attached garage.
Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.
Bedrooms: Each resident bedroom will accommodate any non-ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm.
Bathrooms: All three bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Hand rails were observed near toilets and in showers/tubs. Water temperature measured by applicant and thermometer read by LPA at 120 degrees F.
Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet and drawer. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals Laundry area with washer and dryer were located near the secure door to the garage.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2023
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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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 2
FACILITY NUMBER: 365530080
VISIT DATE: 03/15/2023
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Living/Family room: There are a separate living/family areas with safe and adequate seating and furnishings are in good repair. Activities observed in cabinet accessible to residents.
Linens and Hygiene Supplies: An adequate supply of linens was available.
Yards/Outside: The back was completed was a patio with adequate covered area for providing shade. There were no obstructions. There were no bodies of water observed anywhere on the property.
Garage: There was a washer and dryer located near the garage exit from the facility. Laundry detergents and cleaning solutions were secured behind a locked garage door in a secure cabinet inside garage. Garage was organized and free of obstructions.
Emergency Phone Numbers, and Exit Plan: Let-Us-No poster, personal rights were posted. Facility sketch and exit plan. All posted on cork board by front entrance of facility.
General items: The facility included both smoke alarms and carbon monoxide detectors. These were tested and operational. Flashlights for use in the event of an emergency were observed and made available, emergency night lighting was present. Resident records storage space has been allocated to a secure file cabinet in the staff area near the dining room. LPA observed a facility phone and it was verified to be operational.

Care TOOL was utilized, Dementia Care Plan provided, observed and found sufficient. Comp III Presentation completed. No deficiencies observed. A exit interview was conducted, this report was reviewed and provided to Administrator Omotola Adewumi.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC809 (FAS) - (06/04)
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