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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609726
Report Date: 10/07/2024
Date Signed: 10/07/2024 03:14:35 PM

Document Has Been Signed on 10/07/2024 03:14 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 IIIFACILITY NUMBER:
197609726
ADMINISTRATOR/
DIRECTOR:		VASHAN BOBNEYFACILITY TYPE:
735
ADDRESS:44205 RYCKEBOSCH LNTELEPHONE:
(661) 522-3722
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
10/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Vashan BobneyTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Lorena Casillas met with Administrator Vashan Bobney for an unannounced one (1) year Required visit for this facility.

LPA arrived at 10:35 am and was greeted by staff member and Administrator. One (1) client observed in the living room, three (3) clients out in the community. LPA informed the Administrator of the purpose of the visit. Entrance Interview conducted.

Infection control: LPA reviewed facility mitigation plan (approved on 03/13/21) to make sure licensee was following current infection control recommendations.

A tour of the physical plant was conducted with Administrator at 10:40 am. The facility has four (4) bedrooms and two (2) bathrooms, there is no live in staff. The facility is Fire Cleared for four (4) ambulatory and has awake staff.

Living and dining: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a temperature of 74°F. The smoke and carbon monoxide detectors were tested and observed to be operational at 10:50 am.

Kitchen: LPA conducted a tour of the kitchen around 11:00 am and observed there to be sufficient stock of two-day perishable and seven-day non-perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects locked and inaccessible to clients. The medications are stored in a locked cabinet in the kitchen. The Fire extinguisher was observed to be full and last serviced on 06/18/2024.
Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024
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 III
FACILITY NUMBER: 197609726
VISIT DATE: 10/07/2024
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Resident Rooms: LPA observed rooms to have the appropriate bedding. There is a nightstand, chair, and sufficient lighting for each client.

Bathrooms: At 11:10 am LPA observed all bathrooms to have the appropriate wash your hands signs posted. Hot water was tested at 11:30 am and measured within regulation at 119.3 degrees F.

Laundry: LPA observed detergent items located in the locked laundry room.

Physical environment: LPA toured the outside area of the facility at 11:30 am. LPA observed outdoor furniture, with an umbrella. No bodies of water on the premises.

Garage: LPA observed the garage to be attached to the facility and currently being used for extra storage. There is an additional refrigerator for food overflow.

Administrative: LIC500, Bond, and client roster collected. Annual fees are current.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms at 12:45 pm.

Staff Files: LPA conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms at 1:45 pm.

Medications: At 02:00 pm LPA and Administrator reviewed medication and medication records for proper documentation.

Staff/Client Interviews: At 02:15 pm LPA interviewed clients.

There are no deficiencies to report and no citations to be issued. Exit interviewed conducted and a copy of the report was emailed to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024
LIC809 (FAS) - (06/04)
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