<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606998
Report Date: 03/21/2022
Date Signed: 03/21/2022 02:11:48 PM


Document Has Been Signed on 03/21/2022 02:11 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:DIAMOND CREST HOME CARE INC.FACILITY NUMBER:
197606998
ADMINISTRATOR:ROMULO AMARAFACILITY TYPE:
740
ADDRESS:1158 BEAVER WAYTELEPHONE:
(909) 971-3755
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY:6CENSUS: 5DATE:
03/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:47 AM
MET WITH:Shelly Yamashiro - Administrator TIME COMPLETED:
02:30 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
Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management deficiencies visit during a pre-licensing visit on 3/21/22. LPA Flores met with Shelly Yamashiro administrator and explained the reason for the visit.

On 3/21/22 LPA Flores conducted a tour of the facility with Shelly Yamashiro and observed the following deficiencies:
Kitchen: Knives and sharps stored in drawer next to stove not locked. Cleaning supplies kept under the sink cabinet not locked.
Dining room: Medication cabinet not locked during the visit.
Bathroom #2 was observed missing a skid mat/strips in shower.
Outdoor: Passage way on the left side of the home was observed with debris.
File review: Resident #1 and #4 must have a yearly Physician's report on file.
Medication review: Resident's #1,#2,#3,#4,#5 supplements medication was not labeled to reflect physician's orders.

Deficiencies were noted on LIC809D per Title 22 Division 6 Chapter 8.

Exit interview was conducted with Administrator Shelly Yamashiro.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
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 4


Document Has Been Signed on 03/21/2022 02:11 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: DIAMOND CREST HOME CARE INC.
FACILITY NUMBER: 197606998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2022
Section Cited

1
2
3
4
5
6
7
87309 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 evidence by:
8
9
10
11
12
13
14
Based on observation licensee did not ensure knives, poisons (cleaning solutions) were kept under lock at all times which poses an immediate safety, pesonal rights, or health risk to persons in care.
8
9
10
11
12
13
14
Type A
03/22/2022
Section Cited

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care: (h) The following requirements shall apply...: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons...


This requirement is not met as evidence by:
8
9
10
11
12
13
14
Based on observation licensee did not ensure medication in medication cabinet was not kept locked which poses an immediate safety, personal rigths, or health risk for person in care.
8
9
10
11
12
13
14
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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 03/21/2022 02:11 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: DIAMOND CREST HOME CARE INC.
FACILITY NUMBER: 197606998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2022
Section Cited

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care:(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall ...on a prescription blank, maintained in the residents file, and a label on the medication.

This requirement is not met as evidence by:
8
9
10
11
12
13
14
Based on observation licensee did not ensure resident #1,#2,#3,#4,#5 supplements medication are labeled per physician's orders which poses an immediate health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
03/28/2022
Section Cited

1
2
3
4
5
6
7
87465 Medical Assessment: (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year...

This requirement is not met as evidence by:
8
9
10
11
12
13
14
Based on observation and document reviewed licensee did not ensure resident #1 and #3 have a yearly physician's report on file which poses a potential health, safety, personal rights risk to persons in care.
8
9
10
11
12
13
14
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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 03/21/2022 02:11 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: DIAMOND CREST HOME CARE INC.
FACILITY NUMBER: 197606998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2022
Section Cited

1
2
3
4
5
6
7
87303 Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidence by:
8
9
10
11
12
13
14
Based on observation licensee did not ensure a skid mat or strip was place in bathroom's #2 shower which poses a potential health, safety, personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
03/28/2022
Section Cited

1
2
3
4
5
6
7
87307 Pesonal Accomodations: (d) The following space and safety provisions shall apply to all facilities: (6) (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
8
9
10
11
12
13
14
Based on observation licensee did not ensure passageway was kept clean and free of debris, animal feces which poses a potential health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4