197608559-11-20-2023-31-AS-LCAS-CXRSWA-20231120131401

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608559
Report Date: 11/20/2023
Date Signed: 11/20/2023 01:14:14 PM

Document Has Been Signed on 11/20/2023 01:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	DIVINE FUTURES INC.		FACILITY NUMBER:	197608559
ADMINISTRATOR:	PRISCILLA ISORDIA		FACILITY TYPE:	735
ADDRESS:	EAST 3121 AVENUE J-4		TELEPHONE:	(818) 270-6434
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY: 4		CENSUS: 4	DATE:	11/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Priscilla Isordia		TIME COMPLETED:	01:30 PM

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Licensing Program Analysts (LPAs) Lorena Casillas and Evelin Rios arrived at the facility at 09:50 am. LPAs were greeted by staff member Moyosore Giwa. Staff member Alexia Soto Gonzalez walked in shortly after. Administrator Priscilla Isordia arrived at 10:40 am.

A tour of the physical plant was conducted at 10:00 am with staff member Moyosore. The facility has five (5) bedrooms and two (2) bathrooms. It is currently occupied by four (4) clients. One (1) bedroom and one (1) bathroom are designated for staff use only.

Infection control: LPAs reviewed facility mitigation plan (approved on 03/13/21) to make sure licensee was following current infection control recommendations.

Kitchen: LPAs conducted a tour of the kitchen around 10:05 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Per staff Mondays are designated grocery shopping days. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Chemicals, household supplies, and knives are locked and stored under kitchen cabinet.

Living/dining/family: LPAs observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 70°F. LPAs observed a cabinet that locks where staff and client files are kept. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 10:08 am. There is one (1) fire extinguisher located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 01/03/2023.

Bedrooms:

LPAs observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each client. LPAs observed sufficient bedding and towels in the hallway closet.
Continued...

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DIVINE FUTURES INC.	FACILITY NUMBER: 197608559
	VISIT DATE: 11/20/2023

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Bathrooms: LPAs observed bathroom to have the appropriated wash your hands signs posted. The bathroom was clean, with soap and paper towels for clients. Hot water was tested at 10:32 am in the client bathroom and measured 117.3 degrees Fahrenheit.

First aid kit furnished and fully equipped.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. Gate was unlocked and easily accessible to open. LPAs observed patio furniture and umbrella to be in good condition.

Administrative: LPAs collected the LIC.500 and resident roster. Annual fees are current.

Resident Files: LPAs conducted a file review of resident records to ensure compliance of licensing forms at 10:40 am.

Staff Files: LPAs conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms at 11:15am. Review of staff records revealed that two (2) out of six (6) staff members were background cleared but were not associated with this facility. Administrator contacted Licensee and stated that Licensee will immediately log onto Guardian and associate staff members.

Medications: At 11:27 am LPAs and staff reviewed medication and medication records for proper documentation.

Staff Interview: LPA’s Conducted staff interviews at 12:03pm.

Client Interviews: LPA’s attempted client interviews at 12:19pm.

An exit interview was conducted citation was issued (refer to 809D) and Civil Penalty assessed (refer to LIC 421BG), appeals rights discussed and provided, and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/20/2023 01:14 PM - It Cannot Be Edited

Created By: Lorena Casillas On 11/20/2023 at 12:27 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DIVINE FUTURES INC.	FACILITY NUMBER: 197608559
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80019(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, Iinterview and record review, the licensee did not comply with the section cited above in two (2) of six (6) staff members not being associated to this facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2023
	Plan of Correction
1 2 3 4	Licensee agreed to associate staff through Guardian or send LIC 9082, LIC 508 with a copy of individuals drivers license/state issued identification to Regional Office. Licensee will send a screenshot copy of completed association to LPA Casillas by POC Date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Nichelle Gillyard

LICENSING EVALUATOR NAME:

Lorena Casillas

LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC809 (FAS) - (06/04)

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