198603604-10-13-2023-28-AS-CWOG-CWKPXB-20231013114205

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603604
Report Date: 10/13/2023
Date Signed: 10/13/2023 11:42:55 AM

Document Has Been Signed on 10/13/2023 11:42 AM - 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:	A BELOVED HOME OF DIAMOND BAR		FACILITY NUMBER:	198603604
ADMINISTRATOR:	DUONG, MY MY		FACILITY TYPE:	740
ADDRESS:	454 S ROCK RIVER RD		TELEPHONE:	(626) 899-6999
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY:	6	CENSUS: 3	DATE:	10/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	My My Duong		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to caregiver Rio Basco and administrator MyMy Dong arrived shortly after and assisted with the visit. The facility is licensed for age range 60 and over. Non-ambulatory of which 1 may be bedridden. Hospice Waiver for 6.

The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Covid-19 Screening for visitor still in place. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan.

2. Operational Requirement: A current Plan of Operation at the facility is completed. Hospice waiver plan and dementia plan was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is for 6 non-ambulatory of which one (1) maybe bedridden. Currently, there's only one bedridden resident in the facility. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place.

3. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: living room, kitchen, four residents bedrooms, two resident's bathroom, staff break room, live in staff room, laundry room and attached garage. Bedroom#1 and #4 has two beds, two chairs, required furniture and beddings and sufficient lighting and closet space. Bedroom#2 and #3 has one bed, one chair, one night stand, drawers, required furniture and beddings and sufficient lighting and closet space. All two residents bathrooms have the required grab bar and non-skid mat. The bathrooms are clean, sanitary and in a good working condition. The hot water in both bathrooms were tested between 112.1 and 113.1 which is within the Title 22 regulation. (See LIC 809C for continuation)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: A BELOVED HOME OF DIAMOND BAR	FACILITY NUMBER: 198603604
	VISIT DATE: 10/13/2023

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All knives and sharp utensils are stored in a locked box in kitchen drawer. All the cleaning solutions and chemicals are stored and locked in the overhead cabinet in the laundry room. The extra linen and personal hygiene products are stored and in the hallway cabinet. LPA inspected the carbon monoxide detectors are working properly. The passageway, patio and walkway are free of obstruction.

4. Staffing: The facility has sufficient number of staffing. The facility has at least one staff with CPR training. The night shift staff also received the facility emergency planned training and has an updated First Aid Training in place.

5. Personnel Record and Training: All the facility staff are over 18 years old, associated and fingerprint cleared with the facility. The administrator is My My Duong and her administrator certificate expiration date on 7/18/2024. All the staff has the required documents in their personnel files which includes: health screening, TB Test result, required training hours and updated first aid certificate.

6. Resident Record/Incident Reports: LPA inspected all three (3) resident files and they all have the required documents which include : face sheet, update physician report, TB test result, needs and service plan, admission agreement, medication record and pre-appraisal assessment. A death report/incident report blinder was reviewed.

7. Resident's Right: LPA observed the Long Term Care Ombudsman poster, CCL complaint poster and personal right in the living room. The facility would provide internet service with at least one internet access device for resident to have video conferencing with their family members if needed.

8. Planned Activities: The facility has a sufficient space to accommodate both indoor and outdoor activities was observed.

9. Food Service: Currently no resident is required modified diet prescribed by the physician. The facility has sufficient 2 days perishable and 7 days non-perishable food supply in the facility. All the food are stored properly.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: A BELOVED HOME OF DIAMOND BAR	FACILITY NUMBER: 198603604
	VISIT DATE: 10/13/2023

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10. Incidental Medical and Dental: LPA inspected three (3) resident medication. The medication is centrally stored and locked in the hallway cabinet. All resident's medication are seemed accurate and updated. All the residents have the 30 days supply of medication. Facility staff also provide transportation to resident medical and dental appointment if needed.

11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610D) in place and its updated on 4/2/23. The last fire/earthquake/flood drill was conducted on 8/1/23, 9/1/23 and 10/1/23. The facility has two temporary alternative shelter location. Records of resident Appraisal and Needs services plans are part of Emergency training.

12. Residents with Special Health Needs: No residents in the facility with prohibited health condition. Currently there's one resident on hospice and one on home health. Individual Service Plan and appraisals are on resident's files for home health and hospice. Half and full bed rails for mobility assistance were observed in resident rooms.

No deficiencies were observed during the visit.

Exit Interview Conducted. A copy of the report was provided to the administrator MyMy Duong.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC809 (FAS) - (06/04)

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