331881143-6-8-2023-56-AS-EMAN-CT6SEQ-20230626134907

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881143
Report Date: 06/08/2023
Date Signed: 06/08/2023 01:50:06 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
03/24/2023 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230324133159

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: 3	DATE:	06/08/2023
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Odiakachukwu Frank Nwonye- Caregiver		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident left the facility without staff supervision.
Staff is not taking resident to doctor appointments.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility to deliver findings for the above complaint allegations. LPA met with Caregiver Odiakachukwu Frank Nwonye and explained the reason for the visit.

The investigation consisted of interviews with staff, an interview with Resident R1, and a review of the facilities documents.

For allegation, Resident left the facility without staff supervision. It was alleged that Resident R1 was outside of the facility near the street unsupervised.

During interviews with staff, staff denied that R1 was outside alone. Staff stated that on 3/20/2023 R1 was outside with Staff S1.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 56-AS-20230324133159

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: 06/08/2023

NARRATIVE

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R1 was throwing rocks at S1, so S1 stepped back, and was standing closer to the entry of the facility to avoid the rocks. Staff stated that R1 is not allowed to leave the facility without supervision. Due to this, there is always a staff member with R1.

During an interview with R1, R1 admitted that they were not outside alone. R1 stated they were outside with S1. R1 admitted they were throwing rocks at S1. R1 stated that they were closer to the street where the person driving by could not see S1. R1 asked the a person driving by if they would call 911. R1 admitted that they like to call 911, and they like to go the hospital.

During document review, LPA reviewed R1’s physician’s report dated 3/17/2023. The physicians report states that R1 cannot leave the facility unassisted. LPA reviewed Special Incident Report (SIR) sent to state licensing dated 3/20/23, SIR states that R1 walked to the street and staff followed R1, R1 refused redirection, and 911 was called by a person in car passing by the facility.

For allegation, Staff is not taking resident to doctor appointments:

During interviews with staff, staff denied not taking R1 to their doctors’ appointments. R1 had an appointment scheduled on 3/22/2023. R1 missed this appointment because R1 was not present at the facility from 3/21/20233 to 3/24/2023. R1 had a rescheduled appointment on 5/1/2023, but the appointment was cancelled by the doctor’s office. On 5/8/2023, R1 was seen by the doctor.

During an interview with R1, R1 stated that the facility takes R1 to their scheduled appointments. R1 could not remember missing a specific doctor’s appointment. R1 admitted that occasionally they make a decision to not go to their doctor appointments.

During document review, LPA reviewed emails between the facility and the doctor’s office discussing the reasoning for missing appointments, as well as attempts to reschedule R1’s appointments. LPA reviewed R1’s daily notes, the notes state that R1 was not present in the facility from 3/21/2023 to 3/24/2023.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 56-AS-20230324133159

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: 06/08/2023

NARRATIVE

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Based on evidence obtained during the investigation, the two (2) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations 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: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

LIC9099 (FAS) - (06/04)

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