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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530226
Report Date: 07/26/2024
Date Signed: 07/26/2024 09:14:39 AM

Document Has Been Signed on 07/26/2024 09:14 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:DIGNITY ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
365530226
ADMINISTRATOR/
DIRECTOR:		ADUBI, DAVIDFACILITY TYPE:
735
ADDRESS:15706 AKRON STTELEPHONE:
(951) 901-9792
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 4CENSUS: 0DATE:
07/26/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Harinder Brar-LicenseeTIME VISIT/
INSPECTION COMPLETED:
09:24 AM
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an announced visit to conduct the Pre-licensing inspection. LPA met with Licensee, Harinder Brar, Kulwinder Dhillon and Administrator David Adubi. The fire clearance was approved on 5/30/2024 for two (2) nonambulatory clients and two (2) ambulatory clients.

The facility has four (4) client bedrooms, three (3) client bathrooms, living room, kitchen, pantry, dining area, office, staff bedroom with bathroom, laundry room, attached garage and back yard. LPA toured the interior and exterior areas of the facility. The following were inspected:

Client Bedrooms: All bedrooms have the required bedding and furniture, such as, clean mattresses/linen, nightstands, dressers, chairs, and lighting.

Client Bathrooms: The bathroom appliances were operating in safe and sanitary condition.

Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for client use. Kitchen appliances and counter top were free of debris and in good repair. The water temperature was measured at 110.6 degrees fahrenheit. There was a locked and secured location where medication, sharps, chemicals and clients/staff files will be stored. There was non-perishable food in the pantry and perishable food in the refrigerator.

Common Sitting Areas: There is adequate seating in the common areas. The facility has a supply of activities for the clients.

Laundry Room/ Garage: The laundry room is upstairs. Chemicals, laundry soap and toiletries were safely locked.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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: DIGNITY ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 365530226
VISIT DATE: 07/26/2024
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Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies were available.

Backyard: There is a shaded patio with no bodies of water in the backyard. There is a shaded table with seating for the all the clients. All passageways were free from obstruction.

Fire extinguisher, carbon monoxide, firearms: There was two charged fire extinguisher, operating smoke detectors and carbon monoxide alarms. The home does not have any firearms and ammunition.

Postings: LPA observed required postings including the visitation policies, emergency/disaster plans, complaint procedures, house rules, and personal rights.

First aid and telephone: The facility was equipped with a complete first aid kit and emergency kits. The facility has a working land line and telephone for clients use.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22. Based on the observations and evaluation of the facility this date, the facility is ready for licensure. Component III was completed.

Licensee will be notified once facility is licensed.

An exit interview was conducted, and a copy of this report LIC809 and LIC809C were discussed and provided with Licensees and Administrator.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC809 (FAS) - (06/04)
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