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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881149
Report Date: 03/30/2022
Date Signed: 03/30/2022 11:30:20 AM

Document Has Been Signed on 03/30/2022 11:30 AM - 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 HOMEFACILITY NUMBER:
331881149
ADMINISTRATOR:OLAYINKA KINGFACILITY TYPE:
735
ADDRESS:18900 STONEWOOD WAYTELEPHONE:
(951) 579-1470
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 4CENSUS: 2DATE:
03/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Olayinka KingTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility 03/30/2022 at 09:30 AM to conduct a health and safety check. LPA Brown identified herself and discussed the purpose of the visit with caregiver Folarin Esther Akanji. Administrator Olayinka King was contacted and arrived at the facility. LPA Brown explained the purpose of the visit due to complaint # 56-AS-20220325084430.

One (1) client in care were present during visit but was sleeping. The other client in care is in the day program. LPA Brown observed no health and/or safety hazards inside the facility. LPA Brown inspected the outside perimeter of the facility and observed no health and/or safety hazards. During the visit, and per records review, LPA Brown observed Staff 2 working and providing care to clients without fingerprint clearance. Staff 2 provided copy of Fingerprint Clearance application and LPA Brown explained to Staff 2 that Fingerprint application was submitted but no Fingerprint Clearance was issued. LPA Brown asked Staff 2 when Staff 2 started working and providing care at the facility and Staff 2 answered since 02/07/2022. LPA Brown requested Staff 2 to leave the facility and come back once Fingerprint Clearance has been issued. LPA Brown will be issuing a deficiency for Staff 2 working and providing care at the facility without fingerprint clearance as this poses immediate risk to clients in care. Also, civil penalty will be assessed in the amount of $500.

LPA Brown inspected facility food supplies and observed more than two (2) days supply of perishable foods and more than seven (7) days supply of non-perishable foods. The needs of the residents in care appears to be met during this inspection.

An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to Administrator Olayinka King .
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
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 03/30/2022 11:30 AM - It Cannot Be Edited


Created By: Melody Brown On 03/30/2022 at 10:54 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 HOME
FACILITY NUMBER: 331881149

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2022
Section Cited
CCR
80019(e)(1)

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80019 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a ...
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Administrator immediately removed Staff 2 (S2) at the facility during the visit.

Administrator stated to submit Statement of Understanding on CCR 80019(e)(1) and submit to LPA Brown by POC due date.
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Based on observation, interviews and record review, the licensee did not comply with the section cited above by allowing Staff 2 to work at the facility without criminal background clearance which poses an immediate 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: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022


LIC809 (FAS) - (06/04)
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