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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881149
Report Date: 10/28/2025
Date Signed: 10/28/2025 02:21:49 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
10/13/2025 and conducted by Evaluator Hannah Rodgers
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20251013085747
FACILITY NAME:DIVINE RESIDENTIAL HOMEFACILITY NUMBER:
331881149
ADMINISTRATOR:SOLOMON OLOWOFACILITY TYPE:
735
ADDRESS:18900 STONEWOOD WAYTELEPHONE:
(951) 571-1799
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY:4CENSUS: 2DATE:
10/28/2025
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Staff Muideen SalamiTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Staff did not ensure fire starter tools were made inaccessible to clients
Staff did not ensure supervision was provided to clients
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Staff Muideen Salami.

On October 13, 2025, it was alleged that staff did not ensure fire starter tools were made inaccessible to clients and staff did not ensure supervision was provided to clients. The Department’s investigation consisted of an unannounced facility visit, records review, and staff and outside source interviews.

According to the allegations received, on October 10, 2025, Client #1 (C1) was in possession of a lighter when they left the facility unsupervised to start fires at a neighbor’s home.

[Continued on LIC9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 56-AS-20251013085747
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 331881149
VISIT DATE: 10/28/2025
NARRATIVE
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Review of C1’s Individual Program Plan dated February 13, 2025, revealed that C1 is provided with a curb-to-curb transportation service to and from their day program. Based on interviews, on October 10, 2025, C1 was transported to the facility from their day program. Interviews with staff and outside sources provided conflicting statements as to whether C1 entered the facility prior to going to the neighbor’s house with the lighter. Also, interviews did not reveal that C1 was at the facility with the lighter nor did it reveal the origins of the lighters and if C1 had the lighter at the facility.

Based on interviews and records review, the investigation did not yield a preponderance of evidence to conclude was that staff did not ensure fire starter tools were made inaccessible to clients and staff did not ensure supervision was provided to clients Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Staff Muideen Salami, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2