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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881149
Report Date: 05/13/2026
Date Signed: 05/13/2026 01:57:02 PM

Document Has Been Signed on 05/13/2026 01:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 HOMEFACILITY NUMBER:
331881149
ADMINISTRATOR/
DIRECTOR:		MUIDEEN SALAMIFACILITY TYPE:
735
ADDRESS:18900 STONEWOOD WAYTELEPHONE:
(951) 579-1799
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 4CENSUS: 4DATE:
05/13/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Licensee, Bolaji Akinmulero; DSP, Oluwayemisi "Yemi" Obolo; DSP, Abiodun "Philip" Abe; and DSP, Mkweha "Ambrose" TIME VISIT/
INSPECTION COMPLETED:
02:05 PM
NARRATIVE
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On May 13, 2026, Licensing Program Analyst (LPA) Andrew Martinez conducted a Case Management - Deficiencies inspection while on visit to the facility to conduct a complaint investigation on Control Number 56-AS-20260507101216. Licensee, Bolaji Akinmulero, arrived at the facility along with staff member (Direct Support Professional, DSP) Oluwayemisi "Yemi" Obolo after LPAs arrival, where other DSP staff Abiodun "Philip" Abe and Mkweha "Ambrose" were already present along with four (4) clients in care.

During the unrelated complaint visit, a review of facility/client records revealed the facility did not maintain a register of all clients (LIC 9020) to be made immediately available to licensing staff upon request or kept in a central location in the facility. Licensee stated the facility only had individual staff files to provide to LPA for review. LPA informed Licensee that a Register of Facility Clients/Residents (LIC 9020) form must be completed with current information, updated as necessary, and maintained in the facility at all times. LPA also provided Licensee with a copy of Record to be Maintained at the Facility - Adult Residential (LIC 311C) form to inform and provide education to staff on the necessary records required to be at the facility.

Based on LPA's observation and record review, a deficiency is being cited per Title 22, California Code of Regulations and is noted on the attached LIC 809-D form.

An exit interview was conducted with DSP staff member, Abiodun "Philip" Abe, to whom a copy of this Facility Evaluation Report (LIC 809 and LIC 809-D) was discussed and provided along with Licensee Appeal Rights.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Andrew Martinez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/13/2026 01:57 PM - It Cannot Be Edited


Created By: Andrew Martinez On 05/13/2026 at 01:15 PM
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
RIVERSIDE, CA 92507

FACILITY NAME: DIVINE RESIDENTIAL HOME
FACILITY NUMBER: 331881149

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/14/2026
Section Cited
CCR
80071(a)(1)

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80071 Register of Clients (a) In all licensed facilities, the following shall apply: (1) The licensee shall maintain in the facility a register of all clients. The register shall be immediately available to, and copied for, licensing staff upon request. This requirement is not met as evidenced by:
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Licensee is to complete an Register of Facility Clients/Residents LIC 9020 form with current client information, and review the provided Record to be Maintained at the Facility - Adult Residential (LIC 311C) form with all staff. Licensee is to submit a statement of understand of regulations...
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Based on LPA's observation and record review, the facility did not maintain a register of all clients LIC 9020 form in the facility; staff informed LPA only clients file folders were available to LPA for record review which poses a potential health and safety risk to four (4) out of four (4) clients in care.
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regarding forms required to be maintained in the facility and provide a completed copy of LIC 9020, both via email, to LPA by the end of business day on POC due date.

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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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2026


LIC809 (FAS) - (06/04)
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