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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320599
Report Date: 03/19/2026
Date Signed: 03/19/2026 09:53:56 AM

Document Has Been Signed on 03/19/2026 09:53 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:DIVINE RESIDENTIAL CARE FACILITYFACILITY NUMBER:
198320599
ADMINISTRATOR/
DIRECTOR:		FULLER, DEANNAFACILITY TYPE:
740
ADDRESS:139 W 111TH PLACETELEPHONE:
(562) 209-8094
CITY:LOS ANGELESSTATE: CAZIP CODE:
90061
CAPACITY: 6CENSUS: 0DATE:
03/19/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Deanna FullerTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On 03/19/2026 at approximately 8:00 AM, Licensing Program Analyst (LPA) Jose Anguiano conducted a subsequent pre-licensing inspection to verify corrections identified during the initial pre-licensing inspection conducted on 02/20/2026. LPA met with applicant/licensee Deanna Fuller.

During this visit, LPA observed the following:

1. Bathroom #1 and Bathroom #2: Grab bars adjacent to the toilet and bathing areas were installed.

2. Internet and device are present in the facility; installation is pending. Licensee will notify LPA once operational prior to resident admission.

3. The exterior of the facility was observed to be in good repair and free from hazards.

4. At the rear exterior, the garage is enclosed with a mesh covering, contains a vehicle, and is clean and free from obstruction.

5. The open space behind the garage is clean and free of obstruction.

6. The fruit tree has been trimmed and is safe and accessible to residents.

7. At the rear left exterior, a black privacy screen has been installed along the fence separating the facility from the neighboring property.

8. At the front exterior, a tree requires additional trimming. Licensee will notify LPA upon correction prior to resident admission.

Evaluation Report continues (LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Jose Anguiano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: DIVINE RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 198320599
VISIT DATE: 03/19/2026
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9. Required postings are present; however, the PUB 475 complaint poster will be resized. Licensee will notify LPA upon correction prior to resident admission.

10. A signal call system for residents to request assistance has been installed.

LPA was not granted access to attached back unit of the rear exterior of the facility; therefore, that area was not inspected as licensee did not have access. Based on observations, the majority of corrections have been completed. Items #2, #8, and #9 remain pending and must be completed prior to resident admission.

An exit interview was conducted, and a copy of this report was provided to the applicant, Deanna Fuller. LPA will submit this report to the Central Applications Unit (CAU) for review. The applicant was advised to contact their assigned CAU Analyst for application status updates.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Jose Anguiano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026
LIC809 (FAS) - (06/04)
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