<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881143
Report Date: 09/09/2024
Date Signed: 09/09/2024 03:33:19 PM

Document Has Been Signed on 09/09/2024 03:33 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:DIVINE RESIDENTIAL INCFACILITY NUMBER:
331881143
ADMINISTRATOR/
DIRECTOR:		AKINMULERO, BOLAJIFACILITY TYPE:
735
ADDRESS:31500 SAGECREST DRIVETELEPHONE:
(951) 409-3703
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92532
CAPACITY: 4CENSUS: 4DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:House Manager Olayinka KingTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/09/2024 at 11:15 AM, Licensing Program Analysts (LPA) Melody Brown and Raquel Hernandez conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPAs Brown and Hernandez were greeted by a staff and gained access at the home. House Manager Olayinka King was contacted and informed of the visit. LPAs Brown and Farlow explained the purpose of the visit to House Manager Olayinka King. The facility has four (4) bedrooms, three (3) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPAs Brown and Hernandez completed a walkthrough of the facility, review of records, Personal and Incidental (P&I) audit and medications audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs Brown and Hernandez observed three (3) clients out of four (4) clients during the visit. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPAs Brown and Hernandez inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPAs Brown and Hernandez inspected client bathrooms; LPAs observed broken bathroom drawer. Also, LPAs observed broken kitchen drawers, broken kitchen tiles, broken dresser in client's bedroom. Moreover, LPAs observed dead insects located inside the kitchen cabinet, a couch in living room that is ripped and outdated and top of oven in kitchen that has cobwebs and oil stains. Deficiency will be issued. LPAs observed common towels located in kitchen.


Technical assistance will be issued. Water temperatures tested at 105 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher. However, LPAs observed incomplete first aid kit and no first aid book. Deficiencies will be issued.

Posters such as; the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPAs Brown and Hernandez observed no night lights at the hallway leading to clients' shared bathrooms.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 INC
FACILITY NUMBER: 331881143
VISIT DATE: 09/09/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
**Continuation from LIC809**
Deficiency will be issued. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the right side of the house that leads into the backyard, attached two (2) car garage observed. LPAs observed broken bed with multiple pointed nails coming out of it, chairs, and glass located by outdoor passageway. Deficiency will be issued. Also, LPAs observed broken window screen outside of client's bedroom. Technical violation will be issued.

Food Service: LPAs Brown and Hernandez observed two (2) day(s) supply of perishable food. LPAs observed not enough supply of nonperishable food for at least seven days. Deficiency will be issued. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPAs Brown and Hernandez reviewed two (2) client files for admission agreements, medical assessments/physician reports, Individual Program Plan (IPP). No issues were observed. LPAs Brown and Hernandez also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPAs Brown and Hernandez observed Staff #2 (S2) does not have the required health screening and TB test. Deficiencies will be issued.

LPA Brown and Hernandez audited two (2) clients’ medications and no issues were observed. LPAs Brown and Hernandez audited two (2) client's Personal and Incidental (P&I) and no issues observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TA, LIC9102TV and Appeal Rights were discussed, and copies were provided to House Manager Olayinka King.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 09/09/2024 03:33 PM - It Cannot Be Edited


Created By: Melody Brown On 09/09/2024 at 02:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: DIVINE RESIDENTIAL INC
FACILITY NUMBER: 331881143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring all outdoor passageways are free of potential hazards, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
1
2
3
4
Licensee stated to submit proof of bulk pick up schedule to remove the observed broken bed with multiple pointed nails coming out of it, chairs, and glass to LPA Brown by Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring Staff #2 (S2) has the completed required health screening report, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
1
2
3
4
Licensee stated to submit proof of health screening report or medical appointment to complete the required health screening report to LPA Brown on POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 09/09/2024 03:33 PM - It Cannot Be Edited


Created By: Melody Brown On 09/09/2024 at 02:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: DIVINE RESIDENTIAL INC
FACILITY NUMBER: 331881143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review,, the licensee did not comply with the section cited above by not ensuring Staff #2 (S2) has the completed required tuburcluosis test (TB), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
1
2
3
4
Licensee stated to submit proof of TB test or medical appointment to LPA Brown by Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80075(g)
Health-Related Services
(g) If the facility has no medical unit on the grounds, first aid supplies shall be maintained and be readily available in a central location in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the facility has a complete set of first aid kit as required, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
1
2
3
4
Licensee stated to submit proof of purchase of first aid book to LPA Brown by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 09/09/2024 03:33 PM - It Cannot Be Edited


Created By: Melody Brown On 09/09/2024 at 02:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: DIVINE RESIDENTIAL INC
FACILITY NUMBER: 331881143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring the facility is clean, safe, sanitary and in good repair as evidenced of broken kitchen drawers, broken kitchen tiles, broken bathroom drawer, broken dresser in client's bedroom and insects located in kitchen cabinet, a couch in living room that is ripped and outdated and top of oven in kitchen that has cobwebs and oil stains, which poses a potential health, saftey or personal rights risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
1
2
3
4
Licensee stated to repair all broken drawers in the kitchen, bathroom, clients room and submit staff schedule to clean the facility and purchase a new couch and submit proof to LPA Brown by Plan of Correction (POC) due date.
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring nights are maintained in hallways and passages to nonprivate bathroom, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
1
2
3
4
Licensee stated to submit proof of nightlights to LPA Brown by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 09/09/2024 03:33 PM - It Cannot Be Edited


Created By: Melody Brown On 09/09/2024 at 02:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: DIVINE RESIDENTIAL INC
FACILITY NUMBER: 331881143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that facility has a minimum of seven days of nonperishable foods, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
1
2
3
4
Licensee stated to submit proof of seven days supply of nonperishable foods and grocery schedule to LPA Brown by Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 09/09/2024 03:33 PM - It Cannot Be Edited


Created By: Melody Brown On 09/09/2024 at 03:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: DIVINE RESIDENTIAL INC
FACILITY NUMBER: 331881143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(g)(1)(A)
80075 Health Related Services
(g) If the facility has no medical unit on the grounds, first aid supplies shall be maintained and be readily available in a central location in the facility. (1)The supplies shall include at least the following:
(A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring facility had a current first aid manual book, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
1
2
3
4
Licensee stated to submit proof of purchase of current edition of first aid book to LPA Brown by Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


LIC809 (FAS) - (06/04)
Page: 9 of 9