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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002967
Report Date: 07/16/2024
Date Signed: 07/16/2024 10:29:41 AM

Document Has Been Signed on 07/16/2024 10:29 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DIVINE CARE HOMEFACILITY NUMBER:
345002967
ADMINISTRATOR/
DIRECTOR:
OMOLEWA, PIUSFACILITY TYPE:
735
ADDRESS:5401 FEDERAL STREETTELEPHONE:
(916) 418-4336
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY: 3CENSUS: 0DATE:
07/16/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:18 AM
MET WITH:Pius Omolewa, LicenseeTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On July 16, 2024 Licensing Program Analyst DeAnna Williams -Lyons (LPA)arrived to conduct an Annual Inspection. LPA met with Pius Omolewa, Licensee, and informed him the reason for the visit. The facility does not have residents residing at this time.LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms and kitchen. Bathrooms and bedrooms were clean and in good repair. There is a locked storage for medications and toxins. There is no food supply Food due to no Residents supply is adequate for 2-day perishable and 7-day no perishable. Smoke alarms were checked and in good working order. LPA observed an adequate amount of linens and found the first aid kit to be complete.


LPA reviewed 4 staff records. A review of staff records indicates that all facility staff have received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates. Facility is conducted staff training as required.

Per California Code of Regulations, Title 22, no Citations were issued

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610E the Emergency Disaster Plan, and copy of your current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing no later than August 16, 2024,.


LPA and Licensee did not completed The infectious Control questionnaire. No residents to interview at this time.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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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