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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601468
Report Date: 11/03/2022
Date Signed: 11/03/2022 01:01:08 PM


Document Has Been Signed on 11/03/2022 01:01 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:DIMOND CARE IIFACILITY NUMBER:
015601468
ADMINISTRATOR:BLAIN, JOHN F.FACILITY TYPE:
740
ADDRESS:3015 FRUITVALE AVENUETELEPHONE:
(510) 599-2191
CITY:OAKLANDSTATE: CAZIP CODE:
94602
CAPACITY:6CENSUS: 4DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Helen Blain, StaffTIME COMPLETED:
01:15 PM
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On 11/3/2022 starting approximately at 12:30 p.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator and staff Helen Blain and disclosed the purpose of the visit.

Upon entry, LPA toured facility including but not limited to front entrance, bedrooms, bathrooms, common areas, and outdoor areas. There is one central entry point for both facilities for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette and hand washing posters were observed. Facility staff were observed to be wearing proper PPE.

Facility has no kitchen, meals were prepared in the sister facility side by side and delivered to residents, or residents have meals at sister facility. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff, and visitors.

No deficiency cited during visit. Exit interview conducted with staff, and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
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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