198600650-4-28-2023-28-AS-EIRA-CRBRQZ-20230428131423

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600650
Report Date: 04/28/2023
Date Signed: 04/28/2023 01:14:33 PM

Document Has Been Signed on 04/28/2023 01:14 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	DIAMOND GEM HOME CARE		FACILITY NUMBER:	198600650
ADMINISTRATOR:	REMY COLEMAN		FACILITY TYPE:	735
ADDRESS:	2468 LENNOX ST		TELEPHONE:	(909) 626-5307
CITY:	POMONA	STATE: CA	ZIP CODE:	91767
CAPACITY: 6		CENSUS: 6	DATE:	04/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Alice Reyes and Elizabeth Stacy		TIME COMPLETED:	01:30 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 (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Alice Reyes/Facility Quality Assurance Staff. LPA explained the purpose of today's visit. Elizabeth Stacy arrived at approximately 11:10 A.M.. This is a single story home which consists of (3) bedrooms, (2) bathrooms, living room, kitchen, dinning area, laundry room (inside the garage) and attached garage. All Clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements. Operational Requirements: The fire clearance is approved for (4) ambulatory clients and (2) non-ambulatory clients in bedroom #1. Last Fire Drill and Earthquake Drill were conducted 03/252023. Staff are adhering to operational requirements. Refer to LIC 809C for the continuation of this report.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DIAMOND GEM HOME CARE	FACILITY NUMBER: 198600650
	VISIT DATE: 04/28/2023

NARRATIVE

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Physical Plant & Environment Safety: Smoke alarms were tested and operable. Fire extinguisher is located in the kitchen with the last service date of 01/05/2023. Carbon monoxide (in the kitchen) tested and operable. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Hot water supply measured: Kitchen 108.7*. Hallway bathroom: 106.0*. Bathroom in bedroom #1: 106.0*.

Staffing: There is sufficient staffing at the facility. Administrator Certificate for Elizabeth Stacy expires on 02/14/2025. Ms. Stacy is in the process of completing the HIV Training (to be completed within 6 months of obtaining the Administrator Certificate). Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator and S-1 through S-4. Staff have sufficient on-going training. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting, Client Rights and Zero Tolerance.

Client Rights-Information: Client personal rights are posted and included in client files.

Client Records-Incident Reports: LPA reviewed Client files for C-1 through C-5. Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Functional Capabilities Assessment, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.

Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food is properly stored in the refrigerator (clean and well-maintained). An additional refrigerator is located inside the attached garage, Per S-2, there are no clients on special diets. Pesticides and cleaning supplies are kept away from the food preparation areas (locked inside a cabinet). Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Refer to LIC 809C for the continuation of this report.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DIAMOND GEM HOME CARE	FACILITY NUMBER: 198600650
	VISIT DATE: 04/28/2023

NARRATIVE

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Health Related Services The medications are centrally stored and in their original containers. Medications are bubbled packed and stored inside a locked cabinet. LPA reviewed medication for C-1 through C-5. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Incidental Medical Services: Per S-2, there are no clients at this home with incidental medical services nor have a restricted health condition.

Disaster Preparedness: The facility has an Emergency Disaster and Mass Casualty Plan.

No deficiencies noted. Exit interview, appeals rights and a copy of this report was provided to Elizabeth Stacy.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC809 (FAS) - (06/04)

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