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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881143
Report Date: 07/16/2025
Date Signed: 07/16/2025 03:31:03 PM

Document Has Been Signed on 07/16/2025 03:31 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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: 3DATE:
07/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Bolaji AkinmuleroTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Magda Malcore and Renese Howell-Small made an unannounced visit to the facility to conduct a required annual inspection. LPAs identified themselves, met with Administrator Bolaji Akinmulero and discussed the purpose of the visit. The facility is an Adult Residential facility with a license capacity of (4) and a current census (3). LPA conducted an overall inspection, which included, but was not limited to, the following:

Operation/Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. Client outdoor activity space is shaded and enclosed with self latching gates. The facility is equipped with smoke/carbon monoxide alarms, laundry equipment, hallway emergency lighting, covered fireplace and telephone service. Client bedrooms were equipped with beds, nightstands, chairs, and lighting. Client bathrooms were operating in safe conditions. The hot water in client bathrooms tested at 107 degrees F. LPAs observed the couch in the dining area was ripped and the upstairs hallway carpet was heavily stained. Deficiency cited. Sharps, disinfectants, cleaning supplies were kept locked and stored away from food supply. The facility has 24 hour/7 days a week care staff.

Food Service: The kitchen and dining area was maintained clean. The facility has sufficient non-perishable and perishable food for number of clients in care.

Health Related Services: The facility maintains medications in a locked cabinet. At 1:30 p.m., LPA observed client #1 (C1's) 8 a.m. prescribed medications were still in the bubble pack and not administered to the client. There was not documentation as to why medication was not administered to client. Deficiency cited.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2025
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 9
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DIVINE RESIDENTIAL INC
FACILITY NUMBER: 331881143
VISIT DATE: 07/16/2025
NARRATIVE
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Personnel/Client Records: Staff records reviewed had health screenings, criminal record clearances, and first aid/CPR training certifications. Client records were reviewed for Admission's agreements, needs and service plans, medical assessments and Personal & Incidentals (P&I).

Deficiencies were cited during today’s visit in accordance with Title 22 of the California Code of Regulations. An exit interview was conducted, where this report and correction plans were discussed and a copy with appeal rights was provided to Administrator Akinmulero at the conclusion of the visit.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/16/2025 03:31 PM - It Cannot Be Edited


Created By: Magda Malcore On 07/16/2025 at 02:52 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
RIVERSIDE, CA 92507

FACILITY NAME: DIVINE RESIDENTIAL INC
FACILITY NUMBER: 331881143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on LPAs observations, the licensee did not comply with the section cited by having a ripped couch in dining area and having a heavily stained carpet in uptairs hallway; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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The Licensee/Administrator stated that the couched will be repaired and will contract an outside entity to have carpet cleaned by POC due date.
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by client #1 (C1's) 8 A.M. medication was not given and prescribed. No documentation was observed as to why medication was not administered. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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The Licensee/Administrator has agreed to provided inservice staff training on medication management and submit documentation of training to the licensing agency 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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2025


LIC809 (FAS) - (06/04)
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