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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881143
Report Date: 12/20/2021
Date Signed: 12/20/2021 02:40:49 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/22/2021 and conducted by Evaluator Jennifer Semin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211022101518
FACILITY NAME:DIVINE RESIDENTIAL INCFACILITY NUMBER:
331881143
ADMINISTRATOR:AKINMULERO, BOLAJIFACILITY TYPE:
735
ADDRESS:31500 SAGECREST DRIVETELEPHONE:
(951) 409-3703
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92532
CAPACITY:4CENSUS: 3DATE:
12/20/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Bolaji Akinmulero.TIME COMPLETED:
02:56 PM
ALLEGATION(S):
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Staff refused to take resident back into care
Staff moved resident without the consent of the resident

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with caregiver Giselle Montes and Administrator, Bolaji Akinmulero arrived during the visit.
The investigation consisted of interviews and review of records. The first allegation, staff refused to take resident back into care. Staff stated they did not deny Client 1 (C1) to return to the facility. Staff stated they were on the way to pick up C1 and C1 went AWOL from the hospital. C1 stated staff did not say C1 could not return to the facility and admitted to leaving the hospital against medical advice. Reporting party (RP) stated facility staff told RP that C1 would not be returning to the facility and would be moving to another facility licensed by the same licensee.
The second allegation, staff moved resident without the consent of the resident. Staff stated the decision was made by facility staff, C1’s Consumer Services Coordinator (CSC) from Inland Regional Center (IRC) and C1 for C1 to move to another facility owned by the same licensee, as this facility would be a better fit for C1. C1 stated C1 wanted to move to a different facility. Documents indicate that CSC, Administrator and
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/22/2021 and conducted by Evaluator Jennifer Semin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211022101518

FACILITY NAME:DIVINE RESIDENTIAL INCFACILITY NUMBER:
331881143
ADMINISTRATOR:AKINMULERO, BOLAJIFACILITY TYPE:
735
ADDRESS:31500 SAGECREST DRIVETELEPHONE:
(951) 409-3703
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92532
CAPACITY:4CENSUS: 3DATE:
12/20/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Bolaji Akinmulero.TIME COMPLETED:
02:56 PM
ALLEGATION(S):
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Staff did not inform authorized representative of resident's whereabouts
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with caregiver Giselle Montes and Administrator, Bolaji Akinmulero arrived during the visit.
The investigation consisted of interviews and review of records. The allegation, staff did not inform authorized representative of resident’s whereabouts. Staff stated they notified Community Care Licensing and Inland Regional Center (IRC) for any incidents referring to Client 1 (C1). Staff stated they did not forward those documents to C1’s authorized representative. Reporting Party (RP) stated the facility does not notify them of C1’s incidents and whereabouts.
Based on interviews and documentation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 1) is being cited on the attached LIC9099D.
An exit interview was conducted where this report was discussed and provided to Ms. Akinmulero.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20211022101518
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DIVINE RESIDENTIAL INC
FACILITY NUMBER: 331881143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2021
Section Cited
CCR
80061(f)
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80061 Reporting Requirements
The items specified in (b)(1)(A) through (H) above shall also be reported to the client's authorized representative, if any. This regulation was not met as evidence by: Staff stated they did not forward incident report documents to C1’s authorized representative.
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The Licensee shall read the regulation in it's entirety and submit a statement of understanding to CCLD by the POC due date of 12/28/2021.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 18-AS-20211022101518
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DIVINE RESIDENTIAL INC
FACILITY NUMBER: 331881143
VISIT DATE: 12/20/2021
NARRATIVE
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C1 signed and dated the documents for placement. RP stated C1 did not consent to moving to another facility.

Based upon interviews and information gathered, and although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time.

An exit interview was conducted where this report was discussed and provided to Ms. Akinmulero.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4