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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881149
Report Date: 10/27/2021
Date Signed: 10/27/2021 11:20:07 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/22/2021 and conducted by Evaluator Jennifer Semin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211022104415
FACILITY NAME:DIVINE RESIDENTIAL HOMEFACILITY NUMBER:
331881149
ADMINISTRATOR:OLAYINKA KINGFACILITY TYPE:
735
ADDRESS:18900 STONEWOOD WAYTELEPHONE:
(951) 579-1470
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY:4CENSUS: 4DATE:
10/27/2021
UNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Olayinka KingTIME COMPLETED:
11:32 AM
ALLEGATION(S):
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Illegal eviction
Staff did not refill residents medication timely
Staff are not administering medications according to physicians orders
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to investigate and deliver the findings for the above complaint allegations. LPA met with Esther Akanji. Administrator Olayinka King arrived during the visit.
The investigation consisted of interviews and review of records. The first allegation, illegal eviction. Staff stated they did not issue an eviction nor have they told any client they were evicted or could not return. All clients stated staff have never told them they were evicted or that they could not return to the facility. The second allegation, Staff did not refill residents medication timely. Staff stated they refill all client medications in a timely manner. All clients stated their medication prescriptions are always filled and given to them in a timely manner. LPA observed all medications to be filled and an audit was conducted to verify the medcation count is correct. The third allegation, Staff are not administering medications according to physicians orders. Staff stated they administer all client medication according to their physicians order. All clients stated they get their medication according to their physicians order. LPA observed all medication administration records, prescription refill dates and doses and actual medication count to match perfectly.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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 2
Control Number 18-AS-20211022104415
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DIVINE RESIDENTIAL HOME
FACILITY NUMBER: 331881149
VISIT DATE: 10/27/2021
NARRATIVE
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Based upon interviews and information gathered, and 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, therefore the allegations are UNSUBSTANTIATED at this time.
An exit interview was conducted where this report was discussed and provided to Ms. King.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2