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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200787
Report Date: 10/13/2023
Date Signed: 10/13/2023 03:52:55 PM


Document Has Been Signed on 10/13/2023 03:52 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:
079200787
ADMINISTRATOR:REANO-AQUINO, GRACEFACILITY TYPE:
740
ADDRESS:27402 MANON AVENUETELEPHONE:
(510) 786-9982
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:35CENSUS: 35DATE:
10/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Grace AquinoTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Luisa Fontanilla and Alona Gomez conducted a case management visit in connection with the investigation of complaint 15-AS-20230321085000 and met with Grace Aquino.

During the course of investigation, it was revealed that several unlicensed staff checked Resident 1 (R1) blood sugar. In addition, the facility does not have an approved exception to admit/retain R1 who has Diabetes and unable to manage own blood sugar checks.

Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D)

Exit interview was conducted with Grace and Appeal Rights was provided.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
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 10/13/2023 03:52 PM - 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: 10/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2023
Section Cited
CCR
87628(a)

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 87628(a) Diabetes
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.


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Administrator will evaluate 13 diabetic residents to determine who are able to check own blood sugar and will send result to LPA by POC date.
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This requirement is not met as evidenced by: Based on interviews conducted, several unlicensed staff check R1’s blood sugar which poses an immediate threat to the health and safety of clients in care.

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Type A
10/20/2023
Section Cited
CCR876161(a)

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87616(a) Exceptions for Health Conditions
(a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.
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This requirement is not met as evidenced by: Based on interviews conducted, the facility admitted R1 who is diabetic but unable to manage own glucose testing. Curently, facility admitted 13 diabetic residents without approved exception
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Administrator will submit request for exception for residents who are unable to manage diabetes.
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: 10/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2