197609294-10-18-2023-31-AS-LCAS-CWQTQV-20231018145634

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609294
Report Date: 10/18/2023
Date Signed: 10/18/2023 02:57:03 PM

Document Has Been Signed on 10/18/2023 02:57 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 II		FACILITY NUMBER:	197609294
ADMINISTRATOR:	PRISCILLA ISORDIA		FACILITY TYPE:	735
ADDRESS:	3631 E AVENUE H-10		TELEPHONE:	(818) 270-6434
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY: 4		CENSUS:	DATE:	10/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Priscilla Isordia		TIME COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) Lorena Casillas and Evelin Rios met with Administrator Priscilla Isordia for an unannounced one (1) year Required visit for this facility. LPAs arrived at 9:30 am and were greeted by caregiver Geraldine Moreno. One (1) client observed in the living room watching TV, two (2) clients in their bedrooms, and the other client was at day program. The Administrator arrived at 10:30am. LPAs informed the Administrator of the purpose of the visit. Entrance Interview conducted. Infection control: LPAs reviewed facility mitigation plan (approved on 08/18/22) to make sure licensee was following current infection control recommendations. A tour of the physical plant was conducted with caregiver at 9:47am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying four (4) clients. The facility is Fire Cleared for four (4) ambulatory. Food Inspection LPAs conducted a tour of the kitchen at approximately 9:50am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and clear of clutter. LPAs observed all knives, sharp object, and medications locked and inaccessible to clients in care. Continued on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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 II	FACILITY NUMBER: 197609294
	VISIT DATE: 10/18/2023

NARRATIVE

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Living and dining
LPAs observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 71°F. The smoke detectors and dual carbon monoxide detectors were tested and observed to be operational at 9:58am. There is one (1) fire extinguisher located in the kitchen. The Fire extinguisher was observed to be fully charged and last serviced 04/20/2023.
Resident Rooms
LPAs observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each client.
Bathrooms
LPAs observed all bathrooms to have the appropriated wash your hands signs posted. Hot water was tested at 11:20 am and measured within regulation between 105 degrees F and 120.0 degrees F.
Laundry
LPAs observed the laundry room to be locked and inaccessible to clients in care.
Physical environment
LPAs toured the outside area of the facility at 11:09am. LPA observed appropriate outdoor furniture with an umbrella for shade. No bodies of water on the premises.
Garage
LPAs observed the garage to be attached to the facility and currently being used for storage and PPE supplies. The garage is attached to the laundry room and remains locked at all times.
Medications:
At 10:15 am LPAs and staff reviewed medication and medication records for proper documentation.
Staff Files:
LPAs conducted a file review of staff records to insure forms and training are up to date and in compliance with licensing forms at 10:46 am.
Resident Files:
LPAs conducted a file review of resident records to insure compliance of licensing forms at 11:30am.

An exit interview was conducted, and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC809 (FAS) - (06/04)

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