<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602232
Report Date: 03/07/2023
Date Signed: 03/07/2023 03:59:36 PM


Document Has Been Signed on 03/07/2023 03:59 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 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: 5DATE:
03/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Aurea Rongavilla, StaffTIME COMPLETED:
04:10 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
Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection. LPA arrived unannounced and met with Staff, Aurea Rongavilla, who allowed entry. Administrator, Les Dee, arrived shortly thereafter to assist. The purpose for the visit was explained. The facility is licensed for residents ages 60 and over. The fire clearance is approved for (6) non-ambulatory residents of which (1) may be bedridden. There is a hospice waiver approved for 6 residents.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff are cleaning and disinfecting at least 3 times a day and more often for high touched surfaces. Facility has sufficient PPE supplies and has an Infection Control Plan.
Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 4 non-ambulatory and 1 ambulatory residents residing at the facility. The facility has the sufficient amount for liability insurance covering injury to residents and guests.
Physical Plant & Environment Safety: The facility has a swimming pool in the backyard and is surrounded by a locked gate. There are 6 resident bedrooms, 1 staff room, 4 bathrooms (2 communal bathroom, 1 in bedroom #4, and 1 jack and jill bathroom), living room, dining room, kitchen, and attached garage. Facility has an operable smoke detector in each room and a carbon monoxide detector located near resident rooms. Knives, cleaning solutions, and disinfectants are locked, making them inaccessible to residents. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F.
Staffing: There is sufficient staffing at the facility. The administrator's (Les Dee) certificate expires on 10/4/23. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
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 4


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 BAR RCFE INC
FACILITY NUMBER: 198602232
VISIT DATE: 03/07/2023
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
Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement.
Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal, and Resident rights.
Resident Rights-Information: The Complaint poster, Local Ombudsman, and Residents personal rights are posted.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. During the visit today, LPA reviewed all 5 residents' medication and they are being administered as prescribed by the physician.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. The staff received training on appropriately caring for residents with dementia and those on hospice.
LPA interviewed 2 Staff and a resident during the visit. No deficiencies were issued today. Technical advisories were provided. An exit interview was held. A copy of this report, technical advisory notes, and appeal rights were given to the Administrator Les Dee.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4