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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609924
Report Date: 05/28/2025
Date Signed: 05/28/2025 12:02:45 PM

Document Has Been Signed on 05/28/2025 12:02 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/
DIRECTOR:		VASHAN BOBNEYFACILITY TYPE:
735
ADDRESS:3525 E GARNET LANETELEPHONE:
(818) 270-6434
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
05/28/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Vashan BobneyTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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At 10:00 am Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced case management visit. LPA met with Administrator Vashan Bobney and disclosed the reason for the visit.

Today’s case management visit is to follow up on a series of special incident reports (SIR) previously reported between February 2025 to May 2025 by the facility in which Client #1 (C1) is continuously threatening with self-harm. The purpose of the visit is to obtain additional information regarding these incidents. LPA collected copies of documents pertinent to today’s visit. From 10:00 am to 12:00 pm LPA conducted interviews and toured the facility.

On 02/19/25 it was reported by the facility that C1 was speaking the C1’s brother and wanted to visit, however C1’s brother refused the request and C1 called 911 to state that C1 was going to self-harm. When law enforcement showed up C1 expressed that they wanted to be taken to the emergency room but later stated that they were just upset that C1’s brother refused the request to visit. Law enforcement refused to place C1 on a psychiatric hold and C1 returned to their room without further incident.

On 4/28/25 the facility reported that C1 had grabbed a stick and proceeded to scratch their arm, after staff spoke to C1 to calm C1 down, C1 returned to their room.

On 4/29/25 the facility reported that C1 unprovoked called 911 and threatened to self-harm, this time law enforcement did place C1 on a psychiatric hold, and C1 was released a few hours later.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 IV
FACILITY NUMBER: 197609924
VISIT DATE: 05/28/2025
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Subsequently on 5/8/25 and 5/18/25 C1 had similar behaviors with the most recent behavior on 5/27/25. LPA interviewed Administrator who stated that there has been constant contact with McKinley Mental Health, C1’s behaviorist and C1’s DCFS Social Worker to keep them informed of C1’s increasing behaviors. Administrator stated that behaviorist facility has said that they can no longer help C1 with attention seeking behavior and that they are seeking to have C1 institutionalized. Administrator does not agree with this as C1 is not a threat to themselves, all the threats are simply attention seeking and no real actions to self-harm have taken place. Furthermore, C1’s DCFS Social Worker does not agree with behaviorist recommendation and is actively trying to seek a different behaviorist company. Due to C1 being part of the DCFS network, the Administrator has no say in simply switching C1’s providers, however Administrator is actively seeking assistance with North Los Angeles Regional Center, to find another solution other than institutionalizing C1. C1 is currently on a psychiatric hold and was not able to be interviewed. LPA interviewed Staff #1 (S1) who corroborated what Administrator stated saying that C1 does not have a particular trigger, C1 simply likes the attention that is shown when law enforcement and first responders answer the calls. S2 also mentioned that all staff is able to recognize when C1 is going to have a behavior and have been instructed to call 911 if the behavior escalates or is taken outside of facility. Mental Emergency Team (MET) have been called out numerous times as well and have now refused to come to the facility as they recognize C1 and the attention seeking behavior. In the interim, the Administrator is actively following the facility program plan for behaviors, is ensuring that staff are aware of how to protect C1 from self-harm, and is actively seeking further assistance from different agencies to help C1 remain in the home.

Since the facility has taken the appropriate actions to ensure staff are appropriately caring for C1 and that protocols are being followed for C1’s behaviors, there are no deficiencies cited at this time.

Exit interview conducted. Copy of report provided to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC809 (FAS) - (06/04)
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