331881143-5-23-2023-56-AS-EMAN-CSBMK6-20230530094011

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881143
Report Date: 05/23/2023
Date Signed: 05/23/2023 12:20:45 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/01/2022 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220701160135

FACILITY NAME:	DIVINE RESIDENTIAL INC		FACILITY NUMBER:	331881143
ADMINISTRATOR:	AKINMULERO, BOLAJI		FACILITY TYPE:	735
ADDRESS:	31500 SAGECREST DRIVE		TELEPHONE:	(951) 409-3703
CITY:	LAKE ELSINORE	STATE: CA	ZIP CODE:	92532
CAPACITY:	4	CENSUS: 2	DATE:	05/23/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Odiakachukwu Frank Nwonye- Caregiver		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff pushed resident resulting in injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to investigate and deliver findings for the above complaint allegation that was initiated on 7/7/2022. LPA met with Caregiver Odiakachukwu Frank Nwonye and explained the reason for the visit.

For allegation, Staff pushed resident resulting in injury:

During interview with client C1, C1 does not live at the facility as of June 2022. C1’s whereabouts are unknown.

During interviews with staff, the staff stated that there was an incident that occurred on June 30th, 2022, prior to C1 moving out. During this incident, there was a verbal altercation between C1 and two (2) other clients over an unwarranted joke. Staff S1 had the clients move into separate rooms to attempt to calm the clients down. C1 did not calm down. C1 was yelling at S1 and the clients.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20220701160135

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/23/2023

NARRATIVE

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C1 then went into the living room where S1 was sitting at desk with a computer. C1 to hit the computer, the computer fell down, and the LCD screen broke. After hitting the computer, C1 was attempting to attack another client. At this point, S1 called the police. The police came to the facility and separated the clients. C1 apologized to S1 and the clients for the behavior. C1 was calm after the police left the facility. During the interview with S1, S1 denied pushing and injuring C1. S1 stated that the clients were verbally asked to separate, and no physical contact was used. S1 stated that C1 lies and fabricates stories to seek attention.

During document review, LPA reviewed a special incident report sent to state licensing dated June 30th, 2022. The incident report details the same recollection of the incident that was reported in S1’s interview. LPA reviewed C1’s daily progress notes dated June 30th, 2022. C1’s note for this day details of the same recollection of the incident. LPA also reviewed C1’s Individual Program Plan (IPP) that states C1 has lying and attention seeking behaviors.

Based on the evidence found during the investigation, the allegation listed above is deemed UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Caregiver Odiakachukwu Frank Nwonye, along with a copy of the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC9099 (FAS) - (06/04)

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