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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881149
Report Date: 06/30/2023
Date Signed: 06/30/2023 10:03:35 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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/25/2022 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20220325084430
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:
06/30/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Odiakachukwu Nwonye (Frank) CaregiverTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff inappropriately handled resident causing injury.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPA)Bernadette Allen conducted an unannounced visit to the facility to deliver the findings on the allegation above. LPA met with facility staff Odiakachukwu Nwonye (Frank) Caregiver who was informed of the purpose of the visit.

The investigation consisted of interviews with (3) three clients, (2) two staff members, (3) three outside parties and records reviewed. Interviews were conducted with three clients who said the staff members have never handled them in an inappropriate manner. The interviews conducted with (2) two staff members both deny handling C1 or any of the clients in care roughly. There was no witness, or evidence to corroborate the mentioned allegation.
Based on the investigation, the above finding is Unsubstantiated. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report and appeal rights was discussed and provided to Odiakachukwu Nwonye (Frank) at the conclusion of the visit.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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