331881149-8-23-2023-56-AS-EMAN-CV7PUW-20230830113809

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881149
Report Date: 08/23/2023
Date Signed: 08/23/2023 01:56:43 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
08/16/2023 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230816144220

FACILITY NAME:	DIVINE RESIDENTIAL HOME		FACILITY NUMBER:	331881149
ADMINISTRATOR:	OLAYINKA KING		FACILITY TYPE:	735
ADDRESS:	18900 STONEWOOD WAY		TELEPHONE:	(951) 571-1799
CITY:	LAKE ELSINORE	STATE: CA	ZIP CODE:	92530
CAPACITY:	4	CENSUS: 3	DATE:	08/23/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Oladimeji Ganiyu- Caregiver		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Staff did not intervene during an altercation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to investigate and deliver findings for the allegation listed above. LPA stated the purpose of the visit and was granted entry and met with Caregiver Oladimeji Ganiyu. The investigation consisted of client interviews, staff interviews, and document review.

For allegation, Staff did not intervene during an altercation:

Interviews with clients and interviews with the facility staff revealed that there was a verbal altercation between Client C1 and an individual on 5/23/2023. The individual does not live at the facility or work at the facility. The individual was in a car outside of the facility inquiring about an item they alleged C1 had taken from them without permission. C1 was upset over the situation and started hitting the car window with their hands. The facility staff intervened and talked C1 into coming inside the house to calm down. Interviews revealed that there was no physical contact between C1 and the individual.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

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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Control Number 56-AS-20230816144220

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/23/2023

NARRATIVE

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The facility staff was present during the altercation and took steps to ensure C1’s safety. C1 did not obtain any injuries during the altercation. Document review of C1’s daily notes detailed the same situation that was revealed during the interviews.

Overall, there was not enough evidence to collaborate the allegation listed above.

Based on evidence obtained during the investigation, the allegation listed above is deemed UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) was discussed and provided to Caregiver Oladimeji Ganiyu, along with a copy of the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC9099 (FAS) - (06/04)

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