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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881397
Report Date: 04/13/2023
Date Signed: 04/13/2023 04:38:28 PM

Document Has Been Signed on 04/13/2023 04:38 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DIVINE HOMEFACILITY NUMBER:
331881397
ADMINISTRATOR:OMEJE, QUEENFACILITY TYPE:
735
ADDRESS:4800 CREEKRIDGE LNTELEPHONE:
(909) 766-4847
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 4CENSUS: 0DATE:
04/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Oluchi Iwuoha, LicenseeTIME COMPLETED:
09:44 AM
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Licensing Program Analysts (LPAs) Yolanda Delgado and Kathleen Banrasavong conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 9:15 AM, LPA met with Licensee Oluchi Iwuoha. An initial application for Change within Corporation to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Bureau (CAB) on 12/2/2022 for a total capacity of four (4) ambulatory residents. Fire clearance was granted on 1/4/2023. Infection Control Plan on file. LPA Delgado observed the following:
Structure:
Facility was a one-story house with four (4) resident bedrooms, two (2) resident bathrooms, living room, dining area and kitchen. There was an attached two (2) car garage in the front of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.
Bedrooms:
Each resident bedroom #1, #2, #3 and #4 will accommodate any ambulatory resident, bedroom #5 is the office and bathroom #3 is designated for staff. Four (4) resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm.
Bathrooms:
The two (2) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 10:15 AM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 105. degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition.
(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DIVINE HOME
FACILITY NUMBER: 331881397
VISIT DATE: 04/13/2023
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(CONTINUED FROM LIC 809)

and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the facility. Laundry detergents and cleaning supplies were observed in locked cabinet above the laundry machines away from residents.
Living/Family room:
There was a living/family room with TV for all clients.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the facility.
Yards/Outside:
Patio table and five chairs were observed in the backyard; there was a missing tile and broken tile for the table. There was a gate on the South/East side of the property with a self-latching door. All outdoor pathways were free of obstructions. Facility has no swimming pool.
Emergency Phone Numbers, and Exit Plan:
Facility sketch was observed and posted. Personal Rights, Let-Us-No poster, Resident Council Meeting, Emergency Phone numbers and Emergency Disaster Plan observed.
General items:
One (1) fire extinguisher were charged and located in the kitchen; no tag observed. Eight (8) smoke alarms and one (1) carbon monoxide detectors were tested and were observed to be working. Client records will be stored in a locked cabinet in the Office. First Aid kit with required components, and locked area for medication storage was observed in cabinet located in the dining room. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply and the required 72-hour emergency food supply insufficient inside a black tub inside the garage. Component III was completed on this day as well.

(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DIVINE HOME
FACILITY NUMBER: 331881397
VISIT DATE: 04/13/2023
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(CONTINUED FROM LIC 809C)

Pre-Licensing is incomplete and the following corrections to be resolved by 4/20/2023:
obtain a 72-hour emergency food supply
obtain emergency water
replace tiles for outdoor patio table
fire extinguisher is missing tag

An exit interview was conducted, and a copy of this report was given.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
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