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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603738
Report Date: 04/11/2024
Date Signed: 04/11/2024 02:09:49 PM

Document Has Been Signed on 04/11/2024 02:09 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DIVINE VILLAFACILITY NUMBER:
198603738
ADMINISTRATOR/
DIRECTOR:		LIBANG, LEILANIFACILITY TYPE:
734
ADDRESS:244 ANDOVER DRTELEPHONE:
(909) 841-6315
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 5CENSUS: 3DATE:
04/11/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Leilani Libang (Applicant) and Ray LibangTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an announced pre-licensing visit. LPA met with Leilani Libang (Applicant) and Ray Libang. On 03/24/24, the Fire Department granted fire clearance for (5) bedridden clients. This facility is to operate as an Adult Residential Facility for Persons with Special Healthcare Needs (ARFPSHN). There are currently (3) clients residing at this home under the current licensee Andover Home (198601826). Divine Villa (198603738) will be taking over the operation of this home. Note: Per Applicant, the current licensee will be taking all furnishing and applicant will be replacing all items including all utilities once licensure has been granted. Component III was also completed during this visit.

This is a single-story home which consists of (5) bedrooms fully equipped with mechanical lifts, (3) bathrooms of which one (1) is equipped with a mechanical lift, reclining shower chair, shower trolley in client bathroom (located near bedroom #5), living room, kitchen, dining room, laundry room/office, backyard shaded patio area, and attached garage.



The following was observed/inspected:
  • Physical plant is in good repair.
  • Building and grounds are free from hazards.
  • Smoke detectors tested and operable.
  • Fire extinguishers (service date: 12/28/23) (1) is located in the hallway and the other near the kitchen.
  • Telephone (landline) tested and operable. Per Applicant, facility has internet access.
  • Cleaning solutions (under kitchen sink) and sharps are locked in the kitchen.
  • Pantry's cupboards, freezers, stoves, microwaves, refrigerator and counters are clean.
  • Two-day supply of perishables available, seven-day supply of non-perishable available.
  • The dining table and sufficient chairs.

**Refer to LIC 809C for the continuation of this report**
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DIVINE VILLA
FACILITY NUMBER: 198603738
VISIT DATE: 04/11/2024
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  • There is a designated space for Medications to be locked. Medications will be locked inside a medication cart.
  • First Aid Kit inspected.
  • Pesticides and other toxic substances are stored and locked away from food supply.
  • Bedrooms are large enough to allow for easy passage between and comfortable for usage of beds and other required items of furniture. Each client will have their own bedroom.
  • Clients have the appropriate furniture (one chair, nightstand, adequate closet and drawer space).
  • Clients have hospital beds with rails.
  • Oxygen (including signage) observed.
  • There are enough bath towels, hand towels and wash cloths for all clients.
  • Hot water temperature measured the following: Kitchen: 106.0*, Bathroom near bedroom #3: 109.4*, Bathroom near bedroom #5 (primarily for clients): 111.0* and Bathroom near the office: 108.0*
  • Refrigerator, stove, sinks, tubs, toilets and showers operate properly.
  • Facility has a washer and dryer that are fully operational located near the office.
  • Client and staff files will be stored and locked on premises.
  • Window screens are in good repair and windows/blinds are in good repair and operate properly.
  • Outdoors: there is a shade area set up in the backyard to accommodate (5) clients.
  • Hygiene supplies observed.
  • PPE supplies observed.
  • Clients Rights and Emergency Disaster plan to be posted.

No deficiencies observed. Exit interview conducted, copy of report provided to Leilani Libang (Applicant).
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
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