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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530107
Report Date: 06/10/2024
Date Signed: 06/10/2024 04:04:35 PM

Document Has Been Signed on 06/10/2024 04:04 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DIVINE RESIDENTIAL HOME TWOFACILITY NUMBER:
335530107
ADMINISTRATOR/
DIRECTOR:		SOLOMON OLOWOFACILITY TYPE:
735
ADDRESS:53112 SIMPLEX STREETTELEPHONE:
(951) 223-2211
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92532
CAPACITY: 4CENSUS: 3DATE:
06/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Solomon Olowo - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Solomon Olowo - Administrator and was granted entry to the facility. The facility is a (4i) Adult Residential Facility (ARF) with a current census of (3) clients. The facility is a certified vendor for Inland Regional Center (IRC). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Operation/Physical Plant: The facility is maintained at a comfortable temperature. The facility’s Indoor and outdoor passageways were kept free of obstruction. Facility has no swimming pools or similar bodies of water. The facility’s has sufficient indoor and outdoor activity space for clients in care. The facility is equipped with operating laundry equipment, carbon monoxide alarm and telephone service. The facility has a sufficient supply of bed linen and towels for clients in care; however, the facility did not have a sufficient supply of toileting items for clients. A deficiency cited. Client bedrooms were equipped with beds, bed linen, storage space; however the light fixture in bedroom #3 was not operating, the ceiling fan in bedroom #5 had large amounts of dust and the carpet was not maintained clean. Deficiencies cited. Client bathroom toilets, hand washing and showers were in operating condition. The hot water in client bathrooms were maintained at 106- and 116- degrees F. The facility has posted in a common area Ombudsman poster, Community Care Licensing Complaint poster, facility license, and house rules. Medications are centrally store and kept in a locked cabinet.

Food Service: The kitchen and dining areas are maintained clean. The facility has snacks, non-perishable and perishable food for clients in care; however, the kitchen refrigerator was not operating properly and measured at 55 degrees F. A deficiency cited. Sharps, disinfectants and cleaning solutions are kept locked and store away from food areas.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2024
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DIVINE RESIDENTIAL HOME TWO
FACILITY NUMBER: 335530107
VISIT DATE: 06/10/2024
NARRATIVE
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Care & Supervision: The facility has care staff coverage, 24 hours a day, 7 days a week.

Personnel/Client Records: Client registry was centrally stored. Staff records were reviewed for health screenings, criminal record clearances, and first aid/CPR training certifications, and training. Client records were reviewed for admission’s agreements, medical assessments, needs and service plans, Personal and Incidental logs (P&I). Review of client #1 (C1s) file reveals, C1 did not have a P&I record for the month of May. Client #2 (C2s) did not have an admissions agreement and a written placement certification from IRC on file. Deficiencies cited.

Based on observations and records reviewed, Deficiencies were cited per Title 22 of the California Code of Regulations.

An exit interview was conducted where reports (LIC809/LIC809-D/LIC9102) and correction plans were discussed. Copies of the reports were provided with Appeal Rights to the Administrator at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 06/10/2024 04:04 PM - It Cannot Be Edited


Created By: Magda Malcore On 06/10/2024 at 03:07 PM
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 TWO
FACILITY NUMBER: 335530107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(3)
Food Service
(3) Refrigerators shall be large enough to accommodate required perishables and shall maintain a maximum temperature of 45 degrees F (7.2 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above by the kitchen refrigerator was not operating properly and measured at 55 degrees F; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2024
Plan of Correction
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The Licensee shall submit proof of deficiency correction to the Licensing Agency by POC date.
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 06/10/2024 04:04 PM - It Cannot Be Edited


Created By: Magda Malcore On 06/10/2024 at 03:07 PM
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 TWO
FACILITY NUMBER: 335530107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(5)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (5) Feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by not maintaining a sufficient supply of toileting products for clients; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2024
Plan of Correction
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The Licensee shall submit proof of deficiency correction to the Licensing Agency by POC date.
Section Cited
Safeguards for Cash Resources, Personal Property and Valuables
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 06/10/2024 04:04 PM - It Cannot Be Edited


Created By: Magda Malcore On 06/10/2024 at 03:07 PM
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 TWO
FACILITY NUMBER: 335530107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)(1)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: (1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by not maintaining an updated P&I record for Client #1(C1) on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2024
Plan of Correction
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The Licensee shall submit proof of deficiency correction to the Licensing Agency by POC date.
Type B
Section Cited
CCR
80068(a)(1)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any. (1) Prior to admitting a developmentally disabled adult recommended by a Regional Center, the licensee of an ARF shall obtain from the Regional Center written certification which states that there was no objection to the placement by any persons specified in Welfare and Institutions Code Section 4803.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by not maintaining an admissions agreement and a written placement certification from IRC on file for Client #2; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2024
Plan of Correction
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The Licensee shall submit proof of deficiency correction to the Licensing Agency by POC date.
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 06/10/2024 04:04 PM - It Cannot Be Edited


Created By: Magda Malcore On 06/10/2024 at 03:27 PM
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 TWO
FACILITY NUMBER: 335530107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by the light fixture in bedroom #3 was not operating, the ceiling fan in bedroom #5 had large amounts of dust and the carpet was not maintained clean; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2024
Plan of Correction
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The Licensee shall submit proof of deficiency correction to the Licensing Agency by POC date.
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024


LIC809 (FAS) - (06/04)
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