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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881143
Report Date: 10/23/2023
Date Signed: 10/23/2023 11:11:31 AM

Document Has Been Signed on 10/23/2023 11:11 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
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: 2DATE:
10/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ms Bolaji, AdministratorTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility, as a case management visit, to have the Administrator Ms Bolaji sign an amended complaint #18-AS-20210630104147. LPA Prieto toured the facility with Administrator. The facility has 2 clients who were attending Day Program during this visit. LPA Prieto and Ms Bolaji signed the complaint report and a copy with the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2023
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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