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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881149
Report Date: 07/16/2026
Date Signed: 07/16/2026 03:17:22 PM

Document Has Been Signed on 07/16/2026 03:17 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, 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: 2DATE:
07/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Muideen SalamiTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to conduct the required comprehensive inspection. LPA Malcore was granted access to the facility and met with Administrator, Muideen Salami who was informed the purpose of the visit . The facility has a license capacity of four (4) and a current census of two (2) clients in care. The facility is vendorized by Inland Regional Center (IRC). LPA conducted a walk through of the facility and file review; which included and not limited to the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). Indoor/Outdoor passageways were free of obstructions. Outdoor activity space is gated and has sufficient shaded space for client activities. Posters such as; the personal rights, CCLD complaint poster, and emergency telephone numbers, visitor policy, facility sketch, and client personal rights were posted in a common area. The facility has a smoke/carbon alarms, first aid kit, fire extinguisher, window screens, and covered fireplace. Client bedrooms were equipped with: mattresses, nightstands, storage space, and lighting. Client bathroom equipment were operating in safe conditions. The hot water temperature tested at 118 degrees fahrenheit. The facility maintains a locked box and cabinet were Sharps, cleaning supplies, and toxins are stored. Kitchen and dining areas were clean. The facility has a 7-day supply of nonperishable and a 2-day supply of perishables foods. Cups, plates, and utensils were properly stored. LPA observed the exit door leading to the outside back patio was missing the door handle and was patched up with duct tape.


Care & Supervision: Facility has sufficient care staff coverage 24 hours a day, 7 days a week.
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2026
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 HOME
FACILITY NUMBER: 331881149
VISIT DATE: 07/16/2026
NARRATIVE
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Record Review: Client files were reviewed for for admission agreements, medical assessments/physician reports, centrally stored medication list, and Individual Program Plan (IPP). LPA observed no medical assessment for Client #1 (C1) on file. Staff files were reviewed for First Aid/CPR and CPI certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA observed that there was no record of a health screening for Staff#1 (S1).

Deficiencies were cited during today's visit, in accordance with Title 22, division 6, of the California Code of regulations.

An exit interview was conduct were plan of corrections and this report was discussed. A copy of this report with appeal rights was provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/16/2026 03:17 PM - It Cannot Be Edited


Created By: Magda Malcore On 07/16/2026 at 02:16 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: 07/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
80066(a)(10)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not ensuring documentation of a health screening for staff#1 (S1) was maintained for licensing review; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2026
Plan of Correction
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The Licensee shall provide a copy of the S1's health screening to the licensing agency by POC due date.
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:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/16/2026 03:17 PM - It Cannot Be Edited


Created By: Magda Malcore On 07/16/2026 at 02:16 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: 07/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)(1)
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. (1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not maintaining a record of Client#1 (C1's) medical assessment, which includes client's physical/dietary retrictions/capabilities on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2026
Plan of Correction
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The Licensee shall provide documentation of C1's medical assessment to the Licensing Agency by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/16/2026 03:17 PM - It Cannot Be Edited


Created By: Magda Malcore On 07/16/2026 at 02:31 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: 07/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above by not maintaining the facility exit door in good repair. The exit door leading to the outside back patio was missing its door handle and door was patched with tape. Which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2026
Plan of Correction
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The Licensee shall have the door handle repaired and provide proof of repair to the licensing agency by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2026


LIC809 (FAS) - (06/04)
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