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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881149
Report Date: 09/22/2023
Date Signed: 09/22/2023 11:36:18 AM

Document Has Been Signed on 09/22/2023 11:36 AM - 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:OLAYINKA KINGFACILITY TYPE:
735
ADDRESS:18900 STONEWOOD WAYTELEPHONE:
(951) 571-1799
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 4CENSUS: 2DATE:
09/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Administrator Olayinka A King,TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA was granted entry to the facility. The facility is a four (4) bedroom, two (2), bathroom home and, with a kitchen/dining area, living room and attached garage. The facility is an Adult Residential Facility (ARF) level 4I designated home vendor by Inland Regional Center. Licensed capacity is (4) current census (2). LPA was accompanied by caregiver Temitope Sadare to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. All sharps are locked. The hot water temperature tested within regulation at 117 degrees. There was a designated space for client/staff files. During outdoor tour, LPA observed no shaded area with furnished outdoor use for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed two (3) client files for admission agreements, updated physician report, and needs and services plans. LPA reviewed two (2) client medications and verify P&I. LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2023
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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Document Has Been Signed on 09/22/2023 11:36 AM - It Cannot Be Edited


Created By: Mary Rico On 09/22/2023 at 11:24 AM
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: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed no shaded area with furnished outdoor use for clients in care, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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LPA observed no shaded area with furnished outdoor use for clients in care, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

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.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023


LIC809 (FAS) - (06/04)
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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: 09/22/2023
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Based on the observations made during today’s visit, one (1) deficiency were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), (LIC809D), was discussed and provided to Administrator Olayinka A King, along with appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC809 (FAS) - (06/04)
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