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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210056
Report Date: 11/12/2023
Date Signed: 11/12/2023 04:46:03 PM

Document Has Been Signed on 11/12/2023 04:46 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:DIVINE HOPE RESIDENTIAL FACILITYFACILITY NUMBER:
419210056
ADMINISTRATOR:OSCAR OYEMA OMORAGBONFACILITY TYPE:
735
ADDRESS:125 HEMLOCK AVENUETELEPHONE:
(650) 599-0349
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 4CENSUS: 3DATE:
11/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Staff Francis Imarhiagbe TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required visit. LPA met with Staff Francis Imarhiagbe and and explained the reason for the visit. Census:3

LPA Lund & toured/inspected the facility. This is a single story, 4 bedroom, 2 bath home. The following were observed by LPA Lund the kitchen, observed there were sufficient two (2)- day supply of perishable and seven (7)- day supply of non-perishable food present. There was a locked cabinet in the hallway for clients' medications. First -aid supplies, which includes bandages, adhesive tapes, scissors, tweezers, thermometer, and a current first-aid manual was present. All required posters were posted. LPA inspected all the bedrooms. LPA observed in 2 client's bedroom there was no night stand, chest of drawers and lamp. According to staff, this was to prevent clients from hurting themselves because of their behaviors. Auditory devices were in place to monitor exits. LPA observed bathroom floors clean, sanitary and odorless. The hot water temperature in the main bathroom sink was measured at 115 degrees Fahrenheit. Showers had strips and toilets had grab bars.LPA observed exits were clear. LPA did not observe bodies of water on the premises. Outdoor activity space was completely enclosed by a fence with self -closing latches. Indoor and outdoor passageways and stairways were free of obstruction. Stairways, inclines, ramps, open porches, and outside areas accessible to clients were well- lit with sturdy hand railings.
There was an operating telephone available to clients. Fire alarms and smoke alarms were tested, and they operate properly. Carbon monoxide detectors operate properly as well. Fire extinguisher located in kitchen was inspected on November 8, 2019.

Based on the observations made during today’s inspection, deficiencies were cited and copy of report left.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2023
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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Document Has Been Signed on 11/12/2023 04:46 PM - It Cannot Be Edited


Created By: Jason Lund On 11/12/2023 at 04:36 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: 11/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two out of two fire extinguisher's were date November 8, 2019 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2023
Plan of Correction
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The facility will get new fire extinguisher by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Anthony Perez
LICENSING EVALUATOR NAME:Jason Lund
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2023


LIC809 (FAS) - (06/04)
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