015601241-9-19-2024-15-AS-DDOE-D9A2UV-20240919174259

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601241
Report Date: 09/19/2024
Date Signed: 09/19/2024 05:45:16 PM

Document Has Been Signed on 09/19/2024 05:45 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	DIMOND CARE		FACILITY NUMBER:	015601241
ADMINISTRATOR:	BLAIN, JOHN F.		FACILITY TYPE:	740
ADDRESS:	3003 FRUITVALE AVENUE		TELEPHONE:	(510) 436-0823
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94602
CAPACITY:	30	CENSUS: 27	DATE:	09/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Helen Blain Administrator		TIME COMPLETED:	06:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this day, September 19, 2024, at10:30 AM, Licensing Program Analysts (LPAs) David Doidge and Alicia Delmundo arrived unannounced to conduct an annual required inspection. LPAs met with Sarah Chu, Assistant to the Administrator. and informed the reason for visit. Administrator Helen Blain arrived at 11:00 AM. Facility has Infection Control Plan that was submitted on which a copy was received on this day, 09/19/2024. LPAs toured the facility inside out with Helen Blain and Sarah Chu. LPAs inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications and cleaning supplies were observed locked. Facility has smoke and carbon monoxide detectors that were tested, and observed functional. Hot water temperature in the common bathroom was tested, and measured at 105 degrees Fahrenheit. Facility conduct fire drill every quarter last 06/15/2024. Administrator stated will conduct next drill this month. Fire extinguishers were observed fully charge and showed serviced 05/26/2024. LPAs reviewed 5 staff and 5 residents files. Medications inspected and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Record. Facility does not handle resident cash resources.. LPAs observed the following: -at 10:35 AM, front door had two extra locks, one latch one that locks vertically. Continued on 809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: David Doidge	TELEPHONE: (916) 475-5913
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DIMOND CARE	FACILITY NUMBER: 015601241
	VISIT DATE: 09/19/2024

NARRATIVE

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Continued from 809

-at 11:15 AM, fire perimeter fence gate with lock
-at 11:32 AM, ointment found unlocked in common bathroom
-at 11:40 AM, anti fungal spray and razor found unlocked in resident’s room.
-at 11:56 AM, Efferdent dental cleaner found unlocked in resident’s room.
-at 12:14 PM, Lysol spray found unlocked in resident shared toilet.
-at 3:34 PM, quantity of two medication not listed on LIC622. Date filled scratched out by med tech for R4.
-at 4:00 PM, R1, R2 and R3 have half bed rails but no doctor's orders on file.

Administrator provided the following updated/current documents on this day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. $3M Liability Insurance certificate

Administrator to submit Updated Articles of Organization by October 3, 2024.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. $500.00 civil penalty is assessed for fire safety violation for having the perimeter fence locked and front door locked with latch locks. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan and proof of corrections were discussed with the administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: David Doidge	TELEPHONE: (916) 475-5913
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/19/2024 05:45 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DIMOND CARE	FACILITY NUMBER: 015601241
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above. In resident room Lysol spray, razor, antifungal spray, and dental cleaner readily accessible to residents which poses an immediate health, safety and/or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Staff lock all items. Inaddition administrator to in-service the staff and submit prook by POC due date.

Type A

Section Cited

CCR

87202(a)

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in perimeter fence locked and front door with latched locks which pose an immediate health, safety and/or personal rights risks to persons in care. A $500.00 civil penalty is assessed on this day.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Staff removed the locks. In addition, adminiistrator to ensure no lock installed on the perimeter fence and latch locks on the front door. Self-certification to be submitted by 9/20/24.

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	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: David Doidge	TELEPHONE: (916) 475-5913
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/19/2024 05:45 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DIMOND CARE	FACILITY NUMBER: 015601241
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(4)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in R4's medication labels' date filled scratched out by med tech which poses a potential health and/or personal rights risks to persons in care.
	POC Due Date: 10/03/2024
	Plan of Correction
1 2 3 4	Administrator to in-service the staff and submit proof by 10/03/24.

Type B

Section Cited

CCR

87506(a)

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in R4’s 2 medications do not have the quantity listed on LIC622.which pose a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/03/2024
	Plan of Correction
1 2 3 4	Administrator corrected the LIC622 while LPAs were at the facility.

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	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: David Doidge	TELEPHONE: (916) 475-5913
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/19/2024 05:45 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DIMOND CARE	FACILITY NUMBER: 015601241
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. -This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records review, the licensee did not comply with the section cited above in R1, R2 and R3 for having half bed rails but no doctor's order on file which pose a potential health, safety and/or personal rights risks to persons in care.
	POC Due Date: 10/03/2024
	Plan of Correction
1 2 3 4	Corrected. Administrator had the bedrails removed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: David Doidge	TELEPHONE: (916) 475-5913
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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