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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201446
Report Date: 02/12/2025
Date Signed: 02/12/2025 02:08:00 PM

Document Has Been Signed on 02/12/2025 02:08 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:DIANA'S CARE HOMEFACILITY NUMBER:
019201446
ADMINISTRATOR/
DIRECTOR:		REANO-AQUINO, GRACEFACILITY TYPE:
740
ADDRESS:27402 MANON AVENUETELEPHONE:
(510) 786-9982
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 35CENSUS: 35DATE:
02/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Grace Reano-Aquino, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
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On 2/12/2025 at 10:00am, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced 1-Year Required inspection. LPA met with Grace Reano-Aquino, Administrator. The Administrator currently holds a certificate (#6000611740) that expires on 07/07/2025. The facility’s fire clearance was approved for thirty-five (35) residents.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, back and side yard. The facility consists of nineteen (19) total bedrooms, and six (6) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 105.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 3/29/2024. Emergency Disaster Plan was posted and updated on 2/3/2025. Liability Insurance effective date from 11/28/24 to 11/28/2025. First aid kit was observed to be complete.

LPA reviewed four (4) staff files and seven (7) resident file which were all found to be complete.

Continued on LIC809C...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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 02/12/2025 02:08 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 02/12/2025 at 01:39 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DIANA'S CARE HOME
FACILITY NUMBER: 019201446

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 by having dish wash detergent, Lysol, Clorox wipes unlocked underneath kitchen sink, and inside unlock storage outside in the backyard area, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2025
Plan of Correction
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Staff put away and lock up all chemical during inspection. Deficiency Clear.
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
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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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DIANA'S CARE HOME
FACILITY NUMBER: 019201446
VISIT DATE: 02/12/2025
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LPA observed the following deficiency:

· At 12:30pm, LPA observed dish wash detergent, Lysol, Clorox wipes unlocked underneath kitchen sink, and inside unlock storage outside in the backyard area. (Deficiency Clear during visit)

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiency within a 12-month period may result in civil penalties.


Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC809 (FAS) - (06/04)
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