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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881143
Report Date: 09/12/2024
Date Signed: 09/12/2024 03:51:24 PM

Document Has Been Signed on 09/12/2024 03:51 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:
09/12/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Assistant Administrator Olayinka King.TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 09/12/2024 at 12:00 PM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility in order to verify clearance of plans of correction created with Assistant Administrator Olayinka King, from visit on 09/09/2024. LPA Brown met with Assistant Administrator Olayinka King,

The following Plan of Correction (POC)s were cleared at the time of the visit:
The licensee was cited on 09/12/2024 for California Code of Regulations Section 80075(g) Health Related Services. During today's visit and based on record review and interview, LPA Brown observed that the licensee did not submit the required proof of First Aid Kit purchased. Plan of Correction was to obtain or purchase the required first aid kit and submit proof to LPA Brown at Plan of Correction (POC) due date on 09/10/2024. Therefore, the POC was not cleared until today's visit where Assistant Administrator KIng submitted proof of First Aid Kit purchased to LPA Brown. Civil penalties will be assessed in the amount of $100 per day for three (3) days. LPA Brown provided a clearance letter for this deficiency during the visit.

The licensee was cited on 09/12/2024 for California Code of Regulations Section 80075(g)(1)(A) Health Related Services. During today's visit and based on record review and interview, LPA Brown observed that the licensee did not submit the required proof of purchase of current edition of first aid book. Plan of Correction was to obtain or purchase the required current edition of first aid book to LPA Brown by Plan of Correction (POC) due date on 09/10/2024. Therefore, the POC was not cleared until today's visit where Assistant Administrator KIng submitted proof of current edition of first aid book purchased to LPA Brown. Civil penalties will be assessed in the amount of $100 per day for three (3) days. LPA Brown provided a clearance letter for this deficiency during the visit.

An exit interview was conducted and this report, LIC809, LIC421FC with Appeal Rights were discussed and provided to Assistant Administrator Olayinka King.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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