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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600650
Report Date: 02/16/2024
Date Signed: 02/16/2024 01:31:08 PM

Document Has Been Signed on 02/16/2024 01:31 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 CAREFACILITY NUMBER:
198600650
ADMINISTRATOR:REMY COLEMANFACILITY TYPE:
735
ADDRESS:2468 LENNOX STTELEPHONE:
(909) 626-5307
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 6CENSUS: 4DATE:
02/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Staff Elizabeth StacyTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 02/16/2024. LPA Ramirez was met by Administrator Elizabeth Stacy and explained the purpose of the visit. The facility is approved for six (6) developmentally disabled adults, ages 18-59 and bedroom#1 is cleared for two (2) non-ambulatory clients. There are currently four (4) clients residing in the facility and are receiving case management services provided by San Gabriel/Pomona Regional Center.

LPA OBSERVATIONS: The facility is a single-story dwelling located on a residential street. The facility consists of three (3) client bedrooms, one (1) staff bedroom, two (2) bathrooms, kitchen, dining room, living room, front yard, backyard and attached garage.

Front Yard: LPA Ramirez observed front yard to be free of hazards. Front yard was well maintained.

Kitchen: LPA Ramirez observed appliances to be in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed a fully charger fire extinguisher nearby. LPA Ramirez observed facility menu on refrigerator.

SEE 809-C for continuation.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2024
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
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: 02/16/2024
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Dining Room/Living room: Dining room was observed to contain one table with five (5) chairs. Living room was observed to contain plenty of lighting. LPA Ramirez observed a fully charged fire extinguisher nearby. LPA Ramirez observed signs promoting cough and hand washing etiquette in this area. LPA Ramirez observed nearby thermostat to read 72 degrees F.

Linen Closet/Supply Closet: Observed to contain plenty linens, towels, and hygiene products.

Client Rooms 1 - 3: LPA Ramirez observed client bedrooms#1-3 to contain the required linens, furnishings, and lighting.

Bathroom 1-2: LPA Ramirez observed non slip mats in bathrooms showers and grab bars near toilet. LPA Ramirez observed signs promoting proper hand washing etiquette near sink. Water temperature in both bathrooms sinks was measured within 105- 120 degree F.

Backyard: No large bodies of water were observed. LPA Ramirez observed plenty of seating and shade.

Emergency Drills: Last documented disaster drill was conducted on 01/20/2024 and 10/07/2023.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Personnel Records: Personnel records are maintained at the facility. LPA Ramirez reviewed three (3) personnel records.

Client Records: Client files were maintained at facility. LPA Ramirez reviewed four (4) client records. Facility will need to apply for age exception for C1.

Infection Control Plan: LPA Ramirez reviewed current infection control plan.

Exit interview was conducted. A copy of this report, LIC 9102, and appeals rights was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC809 (FAS) - (06/04)
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