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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609726
Report Date: 09/24/2023
Date Signed: 09/24/2023 05:04:25 PM

Document Has Been Signed on 09/24/2023 05:04 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
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:
09/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Vashan BobneyTIME COMPLETED:
05:10 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 Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility 2:20 pm. LPA disclosed to the administrator the purpose of the visit.

LPA conducted a tour of the physical plant at approximately 3:52 pm to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common areas were observed for the ability to safely serve the needs residents. These included the kitchen/dining room combination and living room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to have adequate seating for residents.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The
kitchen food supply was observed and sufficient for the four (4) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with meats and frozen vegetables. Food pantry in closet next to refrigerator. Sharps and toxins are locked under kitchen sink cabinet. Resident medications stored in locked top kitchen cabinet and observed to be inaccessible to residents. Three (3) first aid kits stored in locked kitchen island cabinet observed to be fully stocked. There is one (1) fire extinguisher attached to wall in the kitchen and observed to be charged.

Laundry room is located across from garage door. The appliances observed to be functional. Additional toxins stored in laundry room open shelves. The laundry room observed to be locked an inaccessible to residents in care.

The facility has a total of four (4) bedrooms and two (2) bathrooms for residents. No room designated for staff. The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2023
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: 09/24/2023
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
(Cont from 809)

The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens in hall closet.

Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured for the two (2) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was between 115.6- and 118.5-degrees Fahrenheit.

Backyard has the following: Patio table umbrella and sufficient seating for the residents. Patio furniture observed to be in good repair.

Attached Garage: Used for PPEs and storage.

Smoke detectors/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards. There were no immediate health and safety hazard observed during the day of inspection.

At approximately 2:35 pm, LPA reviewed files for four (4) residing residents. Resident files included medical assessments and needs and services plans. Two random staff files reviewed. Staff files had the appropriate trainings to include First aid/CPR and CPI.

No deficiencies cited.

Exit Interview Conducted / A Copy of the Report Issued
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2