345002967-6-22-2023-59-AS-DAWL-CT2SXJ-20230622141600

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 345002967
Report Date: 06/22/2023
Date Signed: 06/22/2023 02:16:14 PM

Document Has Been Signed on 06/22/2023 02:16 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	DIVINE CARE HOME		FACILITY NUMBER:	345002967
ADMINISTRATOR:	OMOLEWA, PIUS		FACILITY TYPE:	735
ADDRESS:	5401 FEDERAL STREET		TELEPHONE:	(916) 418-4336
CITY:	NORTH HIGHLANDS	STATE: CA	ZIP CODE:	95660
CAPACITY: 3		CENSUS:	DATE:	06/22/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:02 PM
MET WITH:	Pius Omolewa, Administrator.Licensee		TIME COMPLETED:	02:30 PM

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On June 22, 2023 at 1pm, Licensing Program Analyst (LPA) De Anna Williams-Lyons arrived unannounced to conducted an Annual Inspection of the facility to ensure compliance with Title 22 regulations. LPA Lyons met with Pius Omolewa, administrator who assisted LPA day’s inspection. The Administrator certificate expires April 24, 2025. The current census is 0. The facilities Administrator’s Certificate, Emergency Disaster Plan, Resident’s Rights and Facility Sketch was available for viewing. The room temperature was 71 degrees F which is within range.

LPA inspected the interior and the exterior of the facility including the common living spaces, the kitchen, resident bedrooms and bathrooms. In the kitchen area, cabinets and drawers were reviewed. Knives and sharp objects were reviewed to make sure that they were locked and made inaccessible to the residents at all times. LPA observed there to be a sufficient amount of 7-day non-perishable food. Hot water temperatures were taken and measured at 109 degrees F, which is within the allowed range of 105-120 degrees. The freezer is 0 degrees Fahrenheit. There’s appropriate lighting throughout the facility.

The facility is a one-story home. Living rooms, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be sufficient and in good repair. There is a operating telephone available for residents. Resident bedrooms and bathrooms were toured. There are 3 Bedrooms. All rooms had the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. The sink, toilet, bathtub and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. Washer and dryer was present and operating properly. Toxic substances, laundry and cleaning supplies were inaccessible.

To continue see 809-C.....

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DIVINE CARE HOME	FACILITY NUMBER: 345002967
	VISIT DATE: 06/22/2023

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First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use. The facility was observed to have been inspected by Fire Code and in compliance at this time. LPA inspected the exterior grounds of this facility. There are no bodies of water on the premises. The perimeter fence, side gates, and latches were in good repair. Passageways are free of obstruction and potential hazards. There’s a centralized storage area for resident’s medication. Medication cabinet was locked.

LPA's conducted Component III-Operations and Records Keeping Orientation. This orientation consisted of review of compliance expectations, forms, facility visits, civil penalties, and inspection authority. Component III completed.

Licensure pending approval from Central Application Unit .

Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were observed today.

An exit interview was conducted and a copy of this report was given to Pius.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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