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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603738
Report Date: 04/08/2025
Date Signed: 04/08/2025 04:59:35 PM

Document Has Been Signed on 04/08/2025 04:59 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:
04/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:28 PM
MET WITH:Administrator Leilani DivineTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Blanca Gonzalez conducted an unannounced Annual Required Visit on 04/08/2025. LPAs was met by Administrator Leilani Libang and explained the purpose of the visit. This facility is licensed as an Adult Residential Facility for Persons with Special Healthcare Needs (ARFPSHN) and is serviced by San Gabriel/Pomona Regional Center. The facility is licensed to serve four (4) developmentally disabled clients ages 18 and above; of which five (5) may be bedridden. During today’s visit, LPAs observed five (5) staff members providing direct care and supervision to clients in care. LPA Ramirez requested and obtained copies of personnel report, and client roster.

LPA OBSERVATIONS: 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, living room, TV room, kitchen, dining room, laundry room, backyard shaded patio area, and attached garage. Fully charged fire extinguishers were observed throughout the facility.

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. Signs promoting hand washing were observed in this area.

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.

SEE 809-C for continuation.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2025
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 4
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DIVINE VILLA
FACILITY NUMBER: 198603738
VISIT DATE: 04/08/2025
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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. Vacant bedroom#3 mechanical lift was in disrepair. Per Administrator Leilani- Arjo Lift was at the facility on 4/8/25 and a new battery is required. Admin will send LPA proof of replaced battery by 4/15/25 via email. LPA Ramirez observed caution signs indicating “oxygen in use” near entry of client rooms where oxygen was in use.

Bathrooms: Water temperature in bathroom#1 was measured at 113.7 degrees F. Bathroom #2 water temperature was measured at 117.7 degrees F. Mechanical lift in bathroom# 1 was operable and tested during visit. LPA Ramirez observed a shower gurney in bathroom #1. All client bathrooms were observed to be clean and signs promoting hand washing were observed.

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 and tested during visit. LPA Ramirez observed emergency water, food and disaster supplies in garage.

Emergency Drills: Proof of last documented emergency drill was conducted 03/21/25 during AM shift.

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. Administrators Certificate for Leilani Libang with an expiration date of 03/31/26 was observed.

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

No deficiencies were cited. Exit interview conducted with Administrator Libang. A copy of this report, and LIC 9102 was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
LIC809 (FAS) - (06/04)
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