<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609726
Report Date: 08/09/2022
Date Signed: 08/09/2022 11:25:03 AM

Document Has Been Signed on 08/09/2022 11:25 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:DIVINE FUTURES IIIFACILITY NUMBER:
197609726
ADMINISTRATOR:VASHAN BOBNEYFACILITY TYPE:
735
ADDRESS:44205 RYCKEBOSCH LNTELEPHONE:
(661) 522-3722
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Vashan Bobney, AdministratorTIME COMPLETED:
11:35 AM
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 Analyst (LPA) Shira Stamps met with administrator Vashan Bobney for an unannounced one (1) year Required visit for this facility.

LPA arrived at 10:00am and was greeted by a caregiver. One (1) client was observed in the living room playing video games. The rest of the clients were observed to be in their room sleeping, watching TV and/or resting. The Administrator arrived at 10:20am. LPA informed the Administrator of the purpose of the visit.

Infection control: LPA reviewed facility mitigation plan (approved on 03/13/21) to make sure licensee was following current infection control recommendations. Upon arrival LPA was screened by the caregiver and asked all infection control questions. LPA signed-in and sanitize/wash hands was available.

A tour of the physical plant was conducted with the Administrator at 10:35am. 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
LPA conducted tour at the kitchen around 10:35am 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 inaccessible to pests, but deep cleaning is needed for the base boards. LPA observed all knives and sharp object in a locked box under the locked kitchen cabinet along with chemicals/hazardous materials. LPA observed gloves, masks, gowns, and sanitizer stored in a kitchen cabinet. Medication cabinet was located in the kitchen and was observed to be locked and inaccessible to clients in care.
CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DIVINE FUTURES III
FACILITY NUMBER: 197609726
VISIT DATE: 08/09/2022
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
26
27
28
29
30
31
32
Living and dining
LPA observed the living room to be neat and clean along with the dining room. The living room couch was damaged/broken and is to be picked up. The Administrator stated the new couch should arrive on Wednesday 8/10/22. The facility maintains a comfortable temperature at 77°F. The dual smoke detectors and carbon monoxide detectors were tested and observed to be operational at 10:50am. There is one (1) fire extinguisher located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 04/12/22.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each client.

Bathrooms
At 10:53am LPA observed all bathrooms to have non-skid matts and the appropriated wash your hands signs posted. Hot water was tested and measured within regulation at 116.5 degrees F.

Laundry
LPA observed chemicals/hazardous items in the locked laundry room.

Physical environment
LPA toured the outside area of the facility at 10:48am. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Garage
LPA observed the garage to be attached to the facility and is locked at all times. It is currently being used for an extra storage and PPE supplies (over 30 day supply).

Administrative: LPA collected the LIC.500 and the client roster. Annual fee was due on 8/6/22. LPA reviewed staff training records for infection control.

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

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2