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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881143
Report Date: 11/04/2024
Date Signed: 11/04/2024 12:12:03 PM

Document Has Been Signed on 11/04/2024 12:12 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: 3DATE:
11/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Jennifer IwuTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 11/04/2024 at 09:45 AM, Licensing Program Analyst (LPA) Melody Brown met with staff Jennifer Iwu to initiate a Case Management Visit. Administrator Olayinka King was contacted and informed of the visit. The investigation consisted of observation, interviews, and a review of pertinent documentation.

During the tour of the facility, LPA Brown observed the facility does not have the required minimum of seven (7) days of nonperishable foods maintained at the facility. LPA Brown Brown informed staff Iwu that the facility was cited for the same violation on Food Service 85076(d)(1) on 09/09/2024. Civil Penalty of $250.00 will be assessed today and will continue to be assessed of $100.00 per day if not corrected.

An exit interview was conducted, where this report, LIC809, LIC809D, LIC421FC and Appeal Rights were discussed and provided to staff Jennifer Iwu.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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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Document Has Been Signed on 11/04/2024 12:12 PM - It Cannot Be Edited


Created By: Melody Brown On 11/04/2024 at 11:50 AM
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: 11/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2024
Section Cited
CCR
85076(d)(1)

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Food Service 85076 (d)The licensee shall meet the following food supply and storage requirements: (1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods...This requirement is not met as evidenced by:
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Licensee stated to submit proof of seven (7) days supply of nonperishable foods and store receipts to LPA Brown by Plan of Correction (POC) due date.
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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 (7) days of nonperishable foods supply, which poses a potential health, safety or personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024


LIC809 (FAS) - (06/04)
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