198601748-10-25-2023-11-AS-RCLD-CWXV5Z-20231025160845

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601748
Report Date: 10/25/2023
Date Signed: 10/25/2023 04:09:06 PM

Document Has Been Signed on 10/25/2023 04:09 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	DIAMOND STAR ASSISTED LIVING		FACILITY NUMBER:	198601748
ADMINISTRATOR:	MARIA TERESA MATIAS		FACILITY TYPE:	740
ADDRESS:	2038 W. 233RD STREET		TELEPHONE:	(424) 328-0468
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY:	6	CENSUS: 5	DATE:	10/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:58 AM
MET WITH:	Maria Teresa Matias		TIME COMPLETED:	04:15 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 10/25/2023 at 8:58 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – Annual Inspection and met with Maria Matias, Licensee. Five (5) residents and two (2) staff were present during this inspection.

Facility is licensed to serve six (6) non-ambulatory residents. The facility currently has 2 non-ambulatory and 3 bedridden residents. Three (3) residents are receiving Hospice services. The Annual Licensing Fees are current.

The home consists of 1 floor level with: 1 staff room, 4 resident rooms, 2 restrooms, kitchen, dining room, patio and garage.

The licensee accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and hot tub was covered.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between 106.2-107F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher last serviced August 22, 2023 was observed in the kitchen area. LPA tested carbon monoxide detector. Fire Prevention inspected the facility on March 10, 2023.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: DIAMOND STAR ASSISTED LIVING	FACILITY NUMBER: 198601748
	VISIT DATE: 10/25/2023

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
26
27
28
29
30
31
32

5 staff and 5 resident records were reviewed. Two resident medication records were reviewed. Two staff and two residents were interviewed.

Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Licensee Maria Matias.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 10/25/2023 04:09 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: DIAMOND STAR ASSISTED LIVING	FACILITY NUMBER: 198601748
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87606(c)

Care of Bedridden Residents

(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above for three out of five persons in care. LPA did not observe appropriate fire clearance to retain bedridden person nor notification to the fire department of retaining bedridden person which poses a potential safety risk to persons in care.
	POC Due Date: 11/16/2023
	Plan of Correction
1 2 3 4	Licensee will email regina.cloyd@dss.ca.gov the appropriate fire clearance to accept or retain at least three bedridden persons in care prior to the POC due date.

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: Ulysses Coronel	TELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina Cloyd	TELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5