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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210056
Report Date: 04/26/2024
Date Signed: 04/26/2024 02:26:59 PM

Document Has Been Signed on 04/26/2024 02:26 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:DIVINE HOPE RESIDENTIAL FACILITYFACILITY NUMBER:
419210056
ADMINISTRATOR/
DIRECTOR:		OSCAR OYEMA OMORAGBONFACILITY TYPE:
735
ADDRESS:125 HEMLOCK AVENUETELEPHONE:
(650) 599-0349
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 4CENSUS: 3DATE:
04/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Direct Support Professional - Francis ImarhiagbeTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
NARRATIVE
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On 04/26/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection visit. LPA met with direct support professional/caregiver and explained the purpose of today's visit.

This facility is a one story residential home licensed to provide services to adults 18 years of age and older, all of which need to be ambulatory. All clients are out of the facility at day program or outings. LPA toured the facility inside and out with Francis. Resident bedrooms were furnished, clean, and free from uncommon odors. Client bathroom is fully stocked with paper towels, a trash can, toilet paper, and hand soap. Water temperature is tested at 105F. Common areas are fully furnished. Sharps, toxins, and cleaning supplies were locked away and inaccessible to clients. Sharps such as knives are locked in a drawer adjacent to the stove. Medications are locked in a hallway closet adjacent to resident rooms. 7 day and 2 day food supply is in place. 2 refrigerators are present and one freezer in the facility. LPA observed fire extinguishers, a fire pull alarm system, and carbon monoxide detectors to be in working condition. Extinguishers are last inspected on 11/14/2023. Facility is also equipped with full fire sprinkler system. The facility does not have a record of disaster drills being conducted available for review.

LPA reviewed 2 staff files and 1 resident files. Staff files are observed to be complete with up to date training and background clearance. First aid cards for 2 of 2 staff files are observed to have expired on 02/2022. Resident file observed to be up to date with necessary documents. Facility does handle client monies. LPA reviewed 1 of 3 clients money at the facility and it is in place and accurate to the log and monies counted. Facility administrator's certificate is observed as current expiring 10/10/2024.

The following updated forms are being requested to be received by 05/03/2024:

• LIC610E Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• Updated administrator certificate
• LIC9020 Client Roster
• Certificate of Liability Insurance
• Control of property
• Surety bond for resident cash with expiration date

Per California Code of Regulations (CCR) - Title 22 - Deficiencies were observed today on the following LIC809D. Technical violations are cited on attached LIC9102TV.

Report is reviewed with Francis and a copy of the report was provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2024
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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Document Has Been Signed on 04/26/2024 02:26 PM - It Cannot Be Edited


Created By: Jaime Vado On 04/26/2024 at 02:03 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DIVINE HOPE RESIDENTIAL FACILITY
FACILITY NUMBER: 419210056

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2024
Section Cited
CCR
80023(d)(2)

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80023(d)(2) Disaster and Mass Casualty Plan - (d) Disaster drills shall be conducted at least every six months (2) The drills shall be documented and the documentation maintained in the facility for at least one year. This regulation has not been met as evidenced by:
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Facility shall ensure that the facility conducgts disaster drills at lease every six months and it shall be recorded via a log which includes: client names, staff names, time, and date to show that such drills are taking place.
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Based on facility records reviewed, the faility does not have a disaster drill log that was able to be reviewed during today's inspection. LPA cannot confirm drills have been taking place in accordance with this regulation. This can pose an immediated health and safety risk to residents and staff.
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Type B
05/03/2024
Section Cited
CCR80075(f)

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80075(f) Health Related Services (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This regulation has not been met as evidenced by:
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The facility shall ensure that all staff are trained in at least first aid. Plan in writing and evidence of first aid training to be conducted for all staff shall be submitted to the Department.
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Based on faciltiy staff files reviewed, 2 of 2 staff files indicate that first aid cards expired on 02/2022. LPA cannot verify that staff have current first aid training conducted based on the files reviews. This can pose a potential health and safety risk for residents in care.
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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:April Cowan
LICENSING EVALUATOR NAME:Jaime Vado
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024


LIC809 (FAS) - (06/04)
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