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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601748
Report Date: 07/26/2022
Date Signed: 08/05/2022 02:52:09 PM

Document Has Been Signed on 08/05/2022 02:52 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:DIAMOND STAR ASSISTED LIVINGFACILITY NUMBER:
198601748
ADMINISTRATOR:MARIA TERESA MATIASFACILITY TYPE:
740
ADDRESS:2038 W. 233RD STREETTELEPHONE:
(424) 328-0468
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 6DATE:
07/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Norma Graneta/Maria MatiasTIME COMPLETED:
03:00 PM
NARRATIVE
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On 7/26/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a case management - deficiency observed during an unrelated 24-hour complaint visit at this facility. LPA met with House Manager Norma Graneta who assisted with the visit. Administrator Maria Matias arrived later and joined the visit.

Based on LPA Montoya's record reviews, LPA observed Resident #1's physician's report is dated 1/13/2020 and reappraisal report is dated 3/31/2021. Due to medical condition, Resident shall have medical assessment and reappraisal done annually.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, Type B deficiency was observed and being cited today in violation of California Code of Regulations.

Exit interview conducted and a copy of this report and Appeal Rights were provided to Administrator Maria Matias.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
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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Document Has Been Signed on 08/05/2022 02:52 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 07/26/2022 at 01:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: DIAMOND STAR ASSISTED LIVING
FACILITY NUMBER: 198601748

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2022
Section Cited
CCR
87705(c)(5)

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87705 Care of Persons with Dementia
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
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Licensee shall ensure Resident #1' physician's report and appraisal are done annually. Licensee shall submit Resident #1's current physician's report and reappraisal by the POC due date. Proof of correction shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov.
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Based on LPA Montoya's record reviews, LPA observed Resident #1's physician's report is dated 1/13/2020 and reappraisal report is dated 3/31/2021. Due to medical condition, Resident shall have medical assessment and reappraisal done annually. This poses a potential risk to health, safety and/or personal rights to persons in care.
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022


LIC809 (FAS) - (06/04)
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