<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850264
Report Date: 06/14/2022
Date Signed: 06/14/2022 04:37:38 PM


Document Has Been Signed on 06/14/2022 04:37 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:DIVINE CARE FOR THE ELDERLYFACILITY NUMBER:
425850264
ADMINISTRATOR:JOSE, MARINOFACILITY TYPE:
740
ADDRESS:4866 FRANCES STREETTELEPHONE:
(805) 967-5237
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY:6CENSUS: 4DATE:
06/14/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Marino "Mark" Jose, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kristin Kontilis conducted an announced pre-licensing visit to the facility. LPA met with Administrators Marino “Mark” Jose and Anna Jose. LPA arrived at approximately 12:40 PM.

Entrance Interview Conducted:
The facility is a Residential Care Facility for the Elderly (RCFE) with a fire clearance for residents who are ambulatory and/or non-ambulatory. The facility has a hospice waiver for four (4) residents, and will be licensed for residents with a dementia/Alzheimer’s diagnosis.
A tour of the physical environment was conducted. The front entry is a paved driveway leading to the front entrance with an outdoor sitting area conducive for outdoor visitation. The entry way leads into the living room, dining room, and kitchen.
The kitchen is open style with a service counter for food preparation and cabinets surrounding the kitchen area. There is a refrigerator, a microwave, a toaster, a toaster oven, blender, an oven, and a stove. There is an ample amount of cabinets for food and appliance storage. Behind the dining area is an enclosed patio utilized as an office.
A locked medication cabinet is located in a cabinet in the dining area. It contains a first aid kit and medications for residents, residents’ records and personnel documents. The medications and documents will be inaccessible to residents in care.
There are six bedrooms and three bathrooms available to residents. Bedrooms #1, 2, 4, and 6 are private bedrooms with exits to the front yard or backyard. Bedroom #3 is a shared room with an exit to the backyard. Bedroom #5 is allocated for staff only with no access by residents.
The backyard consists of a patio area, paved walkways, trees, planted garden areas and sitting areas conducive for outdoor visitations.
The laundry area is located in a locked closet located in the hallway near Bedrooms 5 and 6. Detergents and cleaning agents kept in the laundry closet and are inaccessible to residents in care.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: DIVINE CARE FOR THE ELDERLY
FACILITY NUMBER: 425850264
VISIT DATE: 06/14/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 There is one fire extinguisher located at the front door of the facility. The fire extinguisher was serviced on 4/17/2022. There are nine (9) dual carbon monoxide/smoke alarms located throughout the facility. LPA observed that the alarms are in good working order.
LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the facility for fire safety, personal accommodations, and food service.
The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked.
LPA determined that the facility has met licensing requirements per Title 22 California Code of Regulations.

Exit interview conducted. Report issued via email.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2