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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609924
Report Date: 12/14/2023
Date Signed: 12/14/2023 01:19:58 PM

Document Has Been Signed on 12/14/2023 01:19 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 IVFACILITY NUMBER:
197609924
ADMINISTRATOR:VASHAN BOBNEYFACILITY TYPE:
735
ADDRESS:3525 E GARNET LANETELEPHONE:
(818) 270-6434
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
12/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Vashan BobneyTIME COMPLETED:
01:35 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 9:40 am and was greeted by caregiver Gretchenal Williams. One (1) client observed in the living room, one (1) client in their bedroom, and the other two (2) clients are hospitalized. The Administrator arrived at 9:45am. LPA informed the Administrator of the purpose of the visit. Entrance Interview conducted.

Infection control: LPA reviewed facility mitigation plan (approved on 07/30/21) to make sure licensee was following current infection control recommendations.

A tour of the physical plant was conducted with Administrator at 10:00 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 will have 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 78°F. The smoke and carbon monoxide detectors were tested and observed to be operational at 10:08 am. The fire extinguisher is located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 01/03/2023.

Kitchen: LPA conducted a tour of the kitchen around 10:10 am 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. LPA observed all knives and sharp objects locked and inaccessible. The medications are stored in a locked cabinet in the kitchen.

Continued...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DIVINE FUTURES IV
FACILITY NUMBER: 197609924
VISIT DATE: 12/14/2023
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Resident Rooms: LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each client.

Bathrooms: At 10:11 am LPA observed all bathrooms to have the appropriate wash your hands signs posted. Hot water was tested at 10:22 am and measured within regulation at 118.9 degrees F.

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

Physical environment: LPA toured the outside area of the facility at 10:20 am. LPA observed outdoor furniture, with an umbrella that was put away due to high winds. 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 are no additional refrigerators or freezers.

Administrative: LIC500 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 10:30 am.

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 11:50 am.

Medications: At 12:11 pm LPA and Administrator reviewed medication and medication records for proper documentation.

Staff Interviews: At 12:25 pm LPA interviewed staff.

Client Interviews: At 12:50 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 given to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC809 (FAS) - (06/04)
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