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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608559
Report Date: 12/09/2024
Date Signed: 12/09/2024 02:38:49 PM

Document Has Been Signed on 12/09/2024 02:38 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/
DIRECTOR:		PRISCILLA ISORDIAFACILITY TYPE:
735
ADDRESS:3121 EAST AVENUE J4TELEPHONE:
(818) 270-6434
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
12/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Priscilla IsordiaTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility at 09:40 am for an unannounced yearly inspection. LPA was greeted by Administrator Priscilla Isordia and LPA explained the reason for the visit.

A tour of the physical plant was conducted at 10:30 am with caregiver. 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: LPA reviewed facility mitigation plan (approved on 03/13/21) to make sure licensee was following current infection control recommendations.

Kitchen: LPA conducted a tour of the kitchen around 10:35 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Mondays are designated grocery shopping days and currently grocery list was being made by staff. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Chemicals, household supplies, and knives, locked and stored under kitchen cabinet. First aid kit furnished and fully equipped.

Common Areas: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 70°F. LPA 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 10:50 am. There is one (1) fire extinguisher located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 01/12/2024.

Continued on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DIVINE FUTURES INC.
FACILITY NUMBER: 197608559
VISIT DATE: 12/09/2024
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Bedrooms: LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each client. LPA observed sufficient bedding and towels in the hallway closet.

Bathrooms: LPA 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 10:40 am in the client bathroom 110.2 degrees Fahrenheit.

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

Administrative: LPA collected the LIC500, Administrator certificate, bond certificate and resident roster. Annual fees are current.

Staff Files: LPA conducted a file review of staff records at 12:00 pm to ensure forms are up to date.



Client Files: LPA conducted a file review of resident records to ensure compliance of licensing forms at 12:25 pm. During client file review LPA observed that one (1) client out of four (4) was missing a medical assessment. Citation issued on 809-D.

Medications: At 01:45 pm LPA and staff reviewed medication and medication records for proper documentation.

Staff Interview: LPA conducted staff interviews at 02:00 pm.

Client Interviews: LPA conducted client interviews at 02:30 pm.

Citation issued. Appeal Rights discussed and issued. Exit interview conducted. Copy of report provided to Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/09/2024 02:38 PM - It Cannot Be Edited


Created By: Lorena Casillas On 12/09/2024 at 01:19 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: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one (1) out of four (4) client records not having a medical assesment, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2024
Plan of Correction
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Administrator discussed with LPA and agreed to have a completed medical assesment by POC due date. Administrator will email completed medical assesment to LPA for proof.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


LIC809 (FAS) - (06/04)
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