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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601748
Report Date: 08/11/2022
Date Signed: 08/15/2022 04:28:18 PM

Document Has Been Signed on 08/15/2022 04:28 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:
08/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:MARIA TERESA MATIASTIME COMPLETED:
03:30 PM
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On 8/11/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a case management - deficiency at the above facility.

While LPA Montoya was investigating an unrelated complaint on 8/11/22, LPA observed two staff (S1 and S2) brought Resident #1 by wheelchair to Bedroom # 4 (Residents #2 & #3's bedroom) and assisted Resident #1 to shower in the bathroom.

Prior to this visit on 7/26/2022, LPA Montoya noticed the bathroom inside bedroom #4 (Residents #2 and #3's bedroom) is huge. LPA asked S1 who uses that bathroom. Staff #1 stated Residents #2 and #3 as well as the other residents take shower in this bathroom. LPA Montoya advised S1 that "No bedroom of a resident shall be used as a passageway to another room, bath or toilet".

California Code of Regulations, Title 22, Division (6) and Chapter (1) are being cited on the attached LIC 9099D.

Exit interview conducted and a hard copy of this report and appeal rights were provided to Administrator Maria Teresa Matias.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
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 08/15/2022 04:28 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 08/11/2022 at 02:37 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: 08/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2022
Section Cited
CCR
87307(a)

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87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement is not met as evidenced by:
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The administrator will ensure no other residents or staff will use the bathroom int bedroom #4. The admistrator will review the section cited and will self-certify that she understood the regulation and will train staff of this regulation. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov.
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Based on LPA's observations during an unrelated complaint visit, two staff brought Resident #1by wheelchair to Residents #2 & #3's bedroom to shower Resident 1 in the bathroom.
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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: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022


LIC809 (FAS) - (06/04)
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