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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603701
Report Date: 02/13/2024
Date Signed: 02/13/2024 01:55:53 PM


Document Has Been Signed on 02/13/2024 01:55 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 RCFEFACILITY NUMBER:
198603701
ADMINISTRATOR:DEE,LESLIE IANFACILITY TYPE:
740
ADDRESS:1652 MAPLE HILL ROADTELEPHONE:
(909) 861-7430
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 6DATE:
02/13/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Les Dee, AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Cynthia Chan and Christian Gutierrez conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. LPA met with the applicant, Andrew Mente and Administrator, Les Dee.

An application was submitted to CCLD for a Change of Ownership of a Residential Care Facility for the Elderly, ages 60 years and older. The fire clearance has been approved for a capacity of 6 residents, which 5 may be non-ambulatory and 1 bedridden. Bedroom #6 is approved for bedridden. The hospice waiver is approved for 4 residents.

Infection Control: The licensee has developed an Infection Control Plan and designated a lead staff to conduct training. Facility has sufficient PPE supplies and will provide on-going training to staff on infection control.


Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 6 residents residing at the facility.
Structure/Physical Plant:
The facility is a single story home with 6 private 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. The facility has a swimming pool in the backyard and is surrounded by a locked gate. The bathrooms have non-skid mats in the shower area and grab bars. 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 was measured between the required range of 105-120 degrees F. The backyard has a table and chairs for residents to use. The facility has auditory devices located by the exit doors and in each of the resident room's sliding doors.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
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 2


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
FACILITY NUMBER: 198603701
VISIT DATE: 02/13/2024
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Food Service:
There is a sufficient food supply of 2 day perishable and at least a week of non-perishable food maintained at the facility. The kitchen is kept clean and sanitary. All the appliances were in working order. Sufficient amount of tableware, dishes, and utensils are observed. The refrigerator is maintained at 40 degrees F or below and the freezer at 0 degrees F or below. The knives and sharps are stored and locked in a cabinet.
Staff and Residents files:
Staff and Residents files are stored and maintained at the facility. LPA reviewed resident and staff files to ensure all required forms are in their files.
Resident Rights/Information: Resident rights, Resident councils, and complaint posters are posted in a prominent area.
Planned Activities: The facility has sufficient space to accommodate indoor and outdoor activities.
Incidental Medical and Dental: Medications are centrally stored and locked inside a kitchen cupboard. The first aid kit contains all the required supplies along with the current first aid manual.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. There is a backup generator available at the facility.
Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. The facility has "no smoking-oxygen in use" signs posted at the facility and in front of the resident's room.

LPA conducted the Component III with the applicant and administrator. The Pre-licensing is complete and the facility has no deficiencies.

An exit interview was held and a copy of this report was given to the applicant.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC809 (FAS) - (06/04)
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