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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610239
Report Date: 08/23/2024
Date Signed: 08/23/2024 02:46:12 PM

Document Has Been Signed on 08/23/2024 02:46 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:DIAMOND CARE FACILITYFACILITY NUMBER:
197610239
ADMINISTRATOR/
DIRECTOR:		WHITE-TILLMAN, WILDAFACILITY TYPE:
735
ADDRESS:1632 AMARGOSA DR.TELEPHONE:
(661) 916-9090
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 3DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Jeanette GonzalezTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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LPA Spaeth conducted an unannounced visit and was greeted by the caregiver and then greeted by the Administrator Jeanette Gonzalez. LPA stated the purpose of the visit was to conduct an annual inspection. The facility is licensed for four ambulatory and one non-ambulatory clients. The Administrator confirmed there are three ambulatory residents living at the facility.

LPA conducted a tour of the facility at 10:00 am until 10:36 am with the Administrator and LPA observed the facility was neat and clean.

Office- LPA Spaeth observed the office area which contained a locked cabinet and a locked closet which contained emergency food, cleaning supplies, resident files, staff files, and the first aid kit. The emergency water supply is stored in the office.

Common Areas – LPA observed the living room contained comfortable seating along with a television. The dining room area contained a dining room table and chairs.

Kitchen – There is a two-day supply of perishable food and a seven-day supply of non-perishable food items. A fire extinguisher is also located in the kitchen.

Clients' Bedrooms - There are four bedrooms in the home which are furnished with a bed, linens, a chair night stand, chest of drawers and a closet.

Backyard - LPA observed the backyard which has a shaded area with seating. The gate leading from the back yard to the front yard was not locked.

Continued on 809-C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DIAMOND CARE FACILITY
FACILITY NUMBER: 197610239
VISIT DATE: 08/23/2024
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Water Temperature - LPA tested the water temperature at 10:30 am 113 degrees F.L

aundry Room - The room contained the washer and dryer.

Garage - LPA observed an additional freezer which contained additional food items.

Smoke and Carbon Monoxide Detectors- The smoke and carbon monoxide detectors were tested at 10:30 am and were operable.

LPA reviewed the residents' files at 10:45 am until 11:15 am and reviewed the staff files at 11:15 am until TIME. There are no issues to report.

LPA reviewed the residents’ medication at 11:15 am until 11:30 am.

There are no deficiencies to report. Exit interview was conducted and a copy of the signed report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
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