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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200787
Report Date: 03/22/2023
Date Signed: 03/22/2023 11:41:27 AM


Document Has Been Signed on 03/22/2023 11:41 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:
079200787
ADMINISTRATOR:REANO-AQUINO, GRACEFACILITY TYPE:
740
ADDRESS:27402 MANON AVENUETELEPHONE:
(510) 786-9982
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:35CENSUS: 35DATE:
03/22/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Grace Aquino, AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
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On this day, March 22, 2023, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a Priority 1 complaint (Complaint # 15-AS-20230321085000). LPA met with Grace Aquino, Administrator, and explained the reason for visit.

LPA toured the facility inside and out including but not limited to living room, kitchen, dining room, bedrooms and bathroom. Food supplies were observed sufficient for 7 days of non-perishable and 2 days of perishable. Hot water measured at 117.8 F in the hallway bathroom. LPA observed Residents were in the activity area watching television. No other activities were being provided to the residents.


Type A deficiency was cited and proof of correction was discussed with Administrator.

Exit interview was conducted and Appeal Rights was provided to Administrator.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/22/2023 11:41 AM - It Cannot Be Edited

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: 079200787

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2023
Section Cited

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87219 Planned Activities
(e) In facilities licensed for sixteen (16) to forty-nine (49) persons, one staff member, designated by the administrator, shall have primary responsibility for the organization, conduct and evaluation of planned activities. This person shall have had at least six (6) months experience in providing planned activities or have completed or be enrolled in an appropriate education or training program.
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By POC date, facility will submit to CCL plan to ensure activities are provided to all residents and to update activity calendar.
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This requirement is not met as evidenced by: Facility did not comply with the above regulation. LPA observed there is no activity person & no activities provided to the residents. Facility had previous citations for not having a designated activity person.
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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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2