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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603738
Report Date: 05/28/2024
Date Signed: 05/28/2024 01:09:47 PM

Document Has Been Signed on 05/28/2024 01:09 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:
05/28/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:36 AM
MET WITH:Administrator Leilani LibangTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Post Licensing Visit on 05/28/2024 at 8:56 am. LPA was met by Direct Support Personnel (DSP) Stacey Worrell and explained the purpose of the visit. Administrator This facility is licensed as an Adult Residential Facility for Persons with Special Healthcare Needs (ARFPSHN) and is vendorized by San Gabriel/Pomona Regional Center. The facility is licensed to serve five (5) developmentally disabled clients ages 18 and above; of which five (5) may be bedridden. LPA Ramirez observed one (1) Registered Nurse, two (2) Direct Support Personnel, and one (1) Licensed Vocational Nurse, providing direct care and supervision to clients. LPA Ramirez requested and obtained copies of personnel Report, and client Roster.

LPA OBSERVATIONS: Tour began at 9:07 am and was led by LPA Ramirez. The facility is a single-story home that contains five (5) bedrooms fully equipped with mechanical lifts, two (2) bathrooms of which one (1) is equipped with a mechanical lift, three (3) bathrooms, living room, TV room, kitchen, dining room, laundry room, staff office, backyard shaded patio area, and attached garage.

Front Yard: Was clean and well maintained. No hazards were observed. Passageways are free of any obstructions.

Kitchen: LPA Ramirez observed appliances to be clean and in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located kitchen cabinet, to be inaccessible to three (3) out of three (3) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to three (3) out of three (3) clients in care. Signs promoting hand washing were observed in this area. Meal plan was observed in this area for three (3) clients in care.

SEE 809-C for continuation.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DIVINE VILLA
FACILITY NUMBER: 198603738
VISIT DATE: 05/28/2024
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Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed plenty of seating and lighting.

Linen Closet: Contained plenty linens, towels, and hygiene products.

Client Rooms 1 - 5: LPA Ramirez observed all resident bedrooms to contain the required linens, furnishings, and lighting. LPA Ramirez observed mechanical lifts in all client bedrooms and were observed to be in working order. LPA Ramirez observed caution signs indicating “oxygen in use” near entry of client rooms where oxygen was in use.

Bathrooms: Water temperatures in bathroom were observed to be within 105 -120 degrees F. Mechanical lift in bathroom# 2 was operable and tested during visit. LPA Ramirez observed a shower gurney in bathroom #2. All client bathrooms were observed to be clean and signs promoting hand washing were observed. LPA Ramirez will issue Technical Violation for disinfecting equipment in bathroom #2. Per facility staff, disinfecting equipment has not been working, however, the facility does not use it to disinfect shower gurney. Facility staff disinfects shower gurney manually after each use.

Laundry Area: LPA Ramirez observed laundry soap and supplies to inaccessible to three (3) out of three (3) clients in care.

Centrally Stored Medications: LPA Ramirez medications cart to be locked and inaccessible to three (3) out of three (3) clients in care.

Backyard: No large bodies of water were observed. Passageways are free of any obstructions.

SEE 809-C for continuation.

Attached Garage: Generator was observed to be operable. LPA Ramirez observed emergency water, food and disaster supplies in garage.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Staff Personnel Files: Four (4) staff files were reviewed, and LPA Ramirez observed various in-house service trainings. Administrator’s Certificate for Leilani T Libang with an expiration date of 02/05/25 was observed.

Client Files: Three (3) client files were reviewed.

Exit interview conducted. No deficiencies observed during this visit. A copy of this report, LIC 9102 was provided via email.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC809 (FAS) - (06/04)
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