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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881149
Report Date: 12/09/2025
Date Signed: 12/09/2025 10:46:22 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
12/01/2025 and conducted by Evaluator Hannah Rodgers
COMPLAINT CONTROL NUMBER: 56-AS-20251201155909
FACILITY NAME:DIVINE RESIDENTIAL HOMEFACILITY NUMBER:
331881149
ADMINISTRATOR:SOLOMON OLOWOFACILITY TYPE:
735
ADDRESS:18900 STONEWOOD WAYTELEPHONE:
(951) 571-1799
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY:4CENSUS: 2DATE:
12/09/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Staff Muideen SalamiTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff did not ensure client had a bed frame.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced visit to initiate and deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Staff Staff Muideen Salami.

On December 1, 2025, it was alleged that staff did not ensure client had a bed frame. According to the allegation received, Client #1 (C1) did not have a frame for their bed. The Department’s investigation consisted of an unannounced facility visit, LPA observations, and staff and client interviews.

LPA toured the facility accompanied by staff and inspected each client bedroom. LPA observed C1’s bedroom to be maintained with a bed, box spring, and frame. Interviews with staff and clients did not reveal that C1 did not have bed frame, nor did clients lack appropriate mattress accommodations.

[CONTINUED ON LIC9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
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 56-AS-20251201155909
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DIVINE RESIDENTIAL HOME
FACILITY NUMBER: 331881149
VISIT DATE: 12/09/2025
NARRATIVE
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Based on interviews and observations, the investigation did not yield a preponderance of evidence to conclude that staff did not ensure client had a bed frame. Based on the foregoing, the allegation is unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Staff Muideen Salami, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2