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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602232
Report Date: 03/25/2022
Date Signed: 03/25/2022 04:50:15 PM


Document Has Been Signed on 03/25/2022 04:50 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:DIAMOND BAR RCFE INCFACILITY NUMBER:
198602232
ADMINISTRATOR:DEE, LESFACILITY TYPE:
740
ADDRESS:1652 MAPLE HILL ROADTELEPHONE:
(626) 644-4321
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 6DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Les Dee.TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Administrator, Les Dee, who assisted with the visit. The purpose of the visit was discussed. Facility is licensed to serve six (6) non-ambulatory residents, age 60 and above, of which one (1) maybe bedridden. Annual licensing fee is current. Administrator certificate is current and the expiration date is 10/04/23. Currently, one (1) hospice resident residing at the facility and no live-in staff.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed.



The facility is a single story house located in a residential neighborhood. LPA toured the facilities physical plant, indoor and outdoor. The facility has a living room, family room, dining room, kitchen, six (6) resident rooms, two (2) common bathrooms, attached two-cars garage, swimming pool, front yard and backyard.

Resident room #4 has a private bathroom with a toilet and washbasin. Resident room #5 and #6 have a Jack and Jill bathroom with a toilet, washbasin and walk-in shower. All the rooms are furnished with appropriate furniture for residents’ comfort. The bathrooms are furnished with grab bars and nonskid surfaces. Common areas are observed for the ability to safely serve the needs of the residents. Smoke detectors and carbon monoxide detector are tested and operable. Fire extinguishers are purchased on 05/04/21 and gauzes show “1” fully charged. Facility maintains a comfortable temperature for residents. Auditory alarm devices to monitor exits are operable. Swimming pool is locked, gated with a wrought iron fence and inaccessible to residents. Backyard has a shaded area for resident use. Interior and exterior space is available to permit residents to wander freely and safely.

(- Continued in LIC 809 C-)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DIAMOND BAR RCFE INC
FACILITY NUMBER: 198602232
VISIT DATE: 03/25/2022
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Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Hot water temperature is 108.6 degrees Fahrenheit which is within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies are observed.

Administrator stated there were no weapons or ammunition on premises, swimming pool was inaccessible to residents at all times.

The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. Medication are centrally stored in a locked cabinet in the kitchen and inaccessible to residents. Resident records are stored in a locked cabinet and inaccessible to residents. Toxic substances are inaccessible to residents. Outdoor facility space used for residents and leisure are completely enclosed by a fence with self-closing gates.

No deficiencies were observed per California Code of Regulations, Title 22.

An exit interview was conducted. This report was discussed with Administrator, Les Dee, who’s signature on this form confirm receipt of these documents. A copy of LIC 809s report was provided.

SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC809 (FAS) - (06/04)
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