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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609924
Report Date: 12/30/2021
Date Signed: 12/30/2021 11:50:14 AM

Document Has Been Signed on 12/30/2021 11:50 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 IVFACILITY NUMBER:
197609924
ADMINISTRATOR:POWELL, ANTHONYFACILITY TYPE:
735
ADDRESS:3525 E GARNET LANETELEPHONE:
(818) 270-6434
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 0DATE:
12/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Anthony Powell, AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Shira Stamps met with Administrator Anthony Powell for an unannounced one (1) year Required visit for this facility. LPA arrived at 9:50am; there was no answer at the door. LPA called Administrator at 9:52am, and Administrator stated there are no residents at this time. The Administrator stated he is forty (40) minutes away, but will leave now to arrive at the facility.

LPA arrived at 10:57am and was greeted by Administrator Anthony Powell. The facility currently has no residents at this time. LPA informed the Administrator of the purpose of the visit.

Infection control: LPA reviewed facility mitigation plan (approved on 07/30/21) to make sure licensee was following current infection control recommendations. Administrator stated upon arrival of guests; they will be screened by the staff and asked all infection control questions. The guest will be asked to sign-in and will be offered to sanitize/wash their hands.

A tour of the physical plant was conducted with Administrator at 11:00am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying no residents. The facility is Fire Cleared for four (4) ambulatory, and will have awake staff.

Resident Rooms
LPA observed two (2) rooms to have the appropriate mattress pad, sheets,and comforter. There is a nightstand and sufficient lighting for each resident room.

Bathrooms
At 11:05am LPA observed all bathrooms to have the appropriated wash your hands signs posted. Hot water was tested at 11:09 am and measured within regulation at 116.9 degrees F. Continued...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2021
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DIVINE FUTURES IV
FACILITY NUMBER: 197609924
VISIT DATE: 12/30/2021
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Laundry
LPA observed chemicals/hazardous items located in the locked laundry room.

Food Inspection
LPA conducted a tour of the kitchen around 11:02am observed the refrigerator to be kept neat and clean. Food storage and preparation areas are care clean and inaccessible to pests. LPA observed all knives and sharp object locked and inaccessible.

Physical environment
LPA toured the outside area of the facility at 11:20am. Administrator stated there will be outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Living and dining
LPA observed the living room to be neat and clean along with the dining room. The facility maintains a temperature of 58°F. The smoke and carbon monoxide detectors were tested and observed to be operational at 11:10am. The fire extinguisher is located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 11/30/21. LPA informed the Administrator to have the fire extinguisher serviced and provide verification once completed. The medications will be stored in a locked cabinet in the kitchen.
Garage
LPA observed the garage to be attached to the facility and currently being used for an extra storage and PPE supplies.

Administrative: Annual fee are past due. LPA informed Administrator to pay annual fees and provide LPA with verification once paid.


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: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
LIC809 (FAS) - (06/04)
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