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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201446
Report Date: 09/05/2024
Date Signed: 09/05/2024 11:16:35 AM


Document Has Been Signed on 09/05/2024 11:16 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:DIANA'S CARE HOMEFACILITY NUMBER:
019201446
ADMINISTRATOR:REANO-AQUINO, GRACEFACILITY TYPE:
740
ADDRESS:27402 MANON AVENUETELEPHONE:
(510) 786-9982
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:35CENSUS: 35DATE:
09/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:Grace Reano-Aquino, Adminstrator TIME COMPLETED:
11:30 AM
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On this day, September 5, 2024, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a case management due to an SOC 341 between resident on resident. LPA met with Grace Aquino, administrator, and informed the reason for visit.

LPA interviewed Administrator regarding the incident. Administrator called and made police report regarding the unwitnessed physical alteration between R1 and R2. R2 was the one that provoke R1, so R1 cannot control R1 anger, but after R1 apology to R2 and everyone that R1 cannot control anger issue. R2 is still in the hospital, due to R2 needs higher level of care. Administrator and R2 family were discussing the higher of care for R2 prior to this incident, because R2 tend to have aggressive combative behavior, and server dementia. R1 is back from John George and continue to take medication daily.

Requesting:

Police report or an incident case number from police

No deficiency observed on this day.

Exit interview conducted and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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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