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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610570
Report Date: 08/12/2024
Date Signed: 08/12/2024 12:05:50 PM

Document Has Been Signed on 08/12/2024 12:05 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 VFACILITY NUMBER:
197610570
ADMINISTRATOR/
DIRECTOR:		POWELL, ANTHONYFACILITY TYPE:
735
ADDRESS:44319 MAHOGANY STREETTELEPHONE:
(818) 270-6434
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 0DATE:
08/12/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Anthony PowellTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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On 08/12/2024 at 09:50 am, Licensing Program Analyst (LPA) Lorena Casillas conducted an announced Pre-Licensing Inspection with Licensee Anthony Powell. An application to operate an Adult Residential Facility (ARF) was received by Community Care Licensing (CCL) on 01/05/2024. A fire clearance was approved on 6/26/2024, for one (1) non-ambulatory client and three (3) ambulatory clients for a total capacity of four (4). Bedroom 1-3 are designated for ambulatory clients and bedroom 4 is for a non-ambulatory client. The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6.

The Component III presentation was conducted from 10:15 am until 11:05 am with Licensee.
A tour of the physical plant was initiated at approximately 11:10 am and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There was an adequate supply of two (2) days perishable and seven (7) days of nonperishable food and dining ware to accommodate a maximum capacity of four (4). Knives will be locked under the kitchen sink within a locked box. Medication will be locked in a kitchen cabinet. The facility has one fire extinguisher that was fully charged on 07/05/2024. It is in the kitchen hallway. There is a first aid kit located in a kitchen cabinet and is equipped with the necessary supplies.

COMMON AREAS: These included the living room and dining room areas, which were equipped with living room furniture, a television, table, and chairs. The dining room table is large enough to accommodate up to four (4) clients. There were no visible immediate hazards. The smoke alarms are hard wired and inter-connected and are functional. The carbon monoxide detector is functional. The facility temperature was at a comfortable 70 degrees Fahrenheit.

Continued LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2024
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 V
FACILITY NUMBER: 197610570
VISIT DATE: 08/12/2024
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BEDROOMS: There are four (4) bedrooms designated for client use. Room #1 is for one (1) ambulatory client. Room #2 is for one (1) ambulatory client. Room #3 is for one (1) ambulatory client. Room #4 is for one (1) non-ambulatory client. The applicant furnished the client’s bedrooms with beds, nightstand, chairs, dresser, bedding, and linen. All rooms have sufficient lighting.

BATHROOMS: The facility has two (2) bathrooms. All bathrooms were observed to have the proper fixtures, and non-skid mats. The hot water delivered in the bathrooms measured 118.5 degrees F.

LAUNDRY ROOM: Cleaning detergents and supplies are locked in the laundry room area.



GARAGE: The garage is used for storage. It holds emergency food containers and water.

STAFF/CLIENT RECORDS: Staff and client records will be stored in a locked cabinet, located in the living room. The applicant was advised to ensure that client and staff records will be accessible to the licensing agency upon request or during inspection. Facility will have awake staff.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. The backyard of the facility has a patio with shade and backyard furniture. The facility backyard has sufficient yard space to accommodate outdoor activities. There is no swimming pool or bodies of water.

Exit Interview was conducted, and a copy of this report was emailed to applicant.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
LIC809 (FAS) - (06/04)
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