197609726-3-21-2024-31-AS-MVAO-D3YUT3-20240403155115

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609726
Report Date: 03/21/2024
Date Signed: 03/21/2024 03:54:55 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2023 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20230518160443

FACILITY NAME:	DIVINE FUTURES III		FACILITY NUMBER:	197609726
ADMINISTRATOR:	VASHAN BOBNEY		FACILITY TYPE:	735
ADDRESS:	44205 RYCKEBOSCH LN		TELEPHONE:	(661) 522-3722
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	4	CENSUS: 4	DATE:	03/21/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Moses Quintana		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff do not meet resident's dietary needs

INVESTIGATION FINDINGS:

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On 3/21/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by caregiver (DSP). LPA explained the purpose of this visit was to deliver the findings for this complaint. The Administrator was called at 2:28 pm and LPA read the report to the Administrator and the caregiver.

The investigation consisted of the following: on 5/23/2023 LPA Spaeth initiated a complaint investigation. LPA toured the physical plant and requested resident documentation. LPA Spaeth interviewed a resident and three staff members. On 3/15/2024, LPA interviewed three residents by phone from 5:00 pm until 7:00 pm. On 3/18/2024 at 11:30 am, LPA requested the resident’s roster, staff work schedule, and a food purchase receipt. LPA Spaeth received the documentation on 3/18/2024.

Cont. on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230518160443

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: DIVINE FUTURES III	FACILITY NUMBER: 197609726
	VISIT DATE: 03/21/2024

NARRATIVE

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The investigation revealed the following: Regarding the allegation, staff do not meet resident’s dietary needs. It’s being alleged a client had lost weight and has experienced hunger. It is also alleged that the clients do not receive enough food to eat and when a client asks for more food, the client is told they must leave food for other residents.

LPA Spaeth interviewed the four (4) out of the four (4) residents (C1, C2, C3, and C4). C1 confirmed they have lost weight due to watching what they eat in order to lose weight. C2, C3, and C4 stated they have not lost weight. C1, C2, C3, and C4 unanimously stated they can receive additional servings when requested and they never go hungry because there is an abundance of food. C1, C2, C3, and C4 also revealed staff have never stated the clients have to leave food for other residents.

LPA also interviewed the Administrator and three (3) out of the five (5) staff members on 3/18/2024. The three staff members (S1, S2, and S3) and the Administrator confirmed the clients have never stated they have been hungry, lost weight or have been told by staff they must leave food for other residents. The Administrator, S1, S2, and S3 unanimously stated the residents are provided additional servings when requested.

It is also alleged the Administrator has not purchased a sufficient supply of food and milk. The Administrator stated they order food from Wal Mart one to two times a week. They also stated the food is dropped off to the facility. The Administrator provided a receipt dated 3/16/2024 which proves the facility receives food from Wal Mart. All the clients (C1, C2, C3, and C4) living in the facility along with the staff members interviewed (S1, S2, and S3) confirmed they have observed the Wal Mart food delivery.

Based on the record review and interviews of staff and clients, the allegation staff did not meet clients’ dietary needs is unsubstantiated.

The Administrator stated the caregiver may sign the 9099 document.

Exit interview conducted, and a copy of the report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024

LIC9099 (FAS) - (06/04)

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