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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366412250
Report Date: 11/13/2023
Date Signed: 11/13/2023 02:37:00 PM


Document Has Been Signed on 11/13/2023 02:37 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 HOME CAREFACILITY NUMBER:
366412250
ADMINISTRATOR:SWANSON, MARY EILEENFACILITY TYPE:
740
ADDRESS:25937 LAWTON AVETELEPHONE:
(909) 796-2783
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 4DATE:
11/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Mary Swanson, AdministratorTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Mary Swanson, Administrator, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) with a current census of (4). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant: Indoor passageways and outdoor passageways are free of obstruction. The facility has no bodies of water. The facility backyard is enclosed with self-latching gates. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s bathrooms were operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured between 105 and 113 degrees F. Resident’s bedrooms have sufficient lighting and furniture in good repair. Facility has operating carbon monoxide alarms and telephone service. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, disaster evacuation plan and emergency telephone numbers.
Medical Related Services: All medication is centrally stored and kept locked, inaccessible to residents in care.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DIVINE HOME CARE
FACILITY NUMBER: 366412250
VISIT DATE: 11/13/2023
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Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner. Pesticides and other cleaning solutions were kept locked and stored away from food areas.
Care & Supervision: Facility has 24-hour care staff. Staff working have California criminal record clearances or exemptions.
Record Review: (2) staff files reviewed were observed to be complete. (3) resident files reviewed were observed to be complete.

Based on observations and record review, no deficiencies were cited during today’s visit.

An exit interview was conducted where this report was discussed and a copy provided to the Administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
LIC809 (FAS) - (06/04)
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