198603903-6-29-2026-28-AS-BPEA-DVHRFX-20260629125954

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603903
Report Date: 06/29/2026
Date Signed: 06/29/2026 01:09:05 PM

Document Has Been Signed on 06/29/2026 01:09 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	DIAMOND BAR RCFE		FACILITY NUMBER:	198603903
ADMINISTRATOR/ DIRECTOR:	YAMASHIRO, SHELLY		FACILITY TYPE:	740
ADDRESS:	1652 MAPLE HILL ROAD		TELEPHONE:	(909) 861-7430
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY: 6		CENSUS: 6	DATE:	06/29/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:19 AM
MET WITH:	Lilyvi Santos - Applicant Shelly Yamashiro - APplicant/Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:15 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) Bennette Pena conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA met with the applicant, Lilyvi Santos and assisted with the visit. Shortly after, Shelly Yamashiro arrived to assist LPA. LPA used the Compliance and Regulatory Enforcement (CARE) tools for the visit today and the following was inspected during the evaluation. Infection Control: The Infection Control Plan has been submitted to CCL and the CAB Analyst. The facility has Infection Control Training Plan. Operational Requirements: The facility has a fire clearance granted by the City of Whittier Fire Department. Fire clearance granted for (5) non ambulatory residents and (1) bedridden in Room #4 only. Liability insurance is current and expires on 03/01/2027. Facility does not handle cash resources for the residents. Telephone is easily accessible and available for residents'' use. Physical Plant and Environment Safety: The facility is a single story house and located in a neighborhood area. The facility consists of living room, activity room, (6) resident bedrooms, (1) staff bedroom, (3 1/2) bathrooms, dining area, kitchen, backyard with swimming pool and laundry area in the attached garage. There are (3) fire extinguishers which were purchased on 12/15/2025. Knives, cleaning solutions, and disinfectants are locked and inaccessible to residents. Hot water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Each bedroom has a smoke detector with the required furniture and sufficient closet space. Bathrooms have hygiene items such as hand soap, toilet paper and non skid mats. Facility has manual pull alarm fire system and combo smoke alarms and carbon monoxide which were tested and operable. Sufficient supply of linens available to permit weekly changing are available. Sufficient personal hygiene supply available. Kitchen cabinets, refrigerator/freezer, oven, microwave, dishwasher, laundry machines are in working condition, clean and sanitary. Doors, exits, hallways, and passageways were clear and free of obstruction. Hated swimming pool was observed in the backyard and has a shaded area and sitting area. Equipment and supplies for indoor activities was observed and available for use. *CONTINUED ON LIC 809-C***

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DIAMOND BAR RCFE	FACILITY NUMBER: 198603903
	VISIT DATE: 06/29/2026

NARRATIVE

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Staffing: The administrator has a current administrator certificate, expiring on 10/05/2027.
Personnel Records-Training: Staff files are maintained at the facility and stored in a locked cabinet.
Residents Rights-Information: Residents personal rights are posted. Facility provides internet service and telephone to the residents.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities.
Food Service: Meals are prepared in a safe manner, necessary to meet the needs of the residents.
Food storage and preparation areas, which include pantries, cupboards, drawers and counters were observed to be clean and appropriate for food preparation. Appliances such as a microwave, refrigerator and stove were observed to be clean and operating properly.
Incidental M & D: The medications are centrally stored in a locked cabinet and in their original containers.
The facility uses the Medication Administration Record (MAR) log to document medications given. A complete first aid kit is maintained.
Resident Records-Incident Reports: Resident files are maintained at the facility and stored in a locked cabinet.
Disaster Preparedness: The home has a complete Emergency and Disaster Preparedness Plan that includes, EVAC Procedures, Transportation arrangements, Location of all utility shut-off valves and instructions for use. There is a contact information list of local emergency response personnel, residents authorized representative or local emergency contact name.
Residents with SHN: (2) residents receive hospice care and (2) are bedridden.

Component III was conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance. Facility met the physical plant requirements/ inspection as required.

An exit interview was conducted, and a copy of this report has been furnished to the Applicants, Lilyvi Santos and Shelly Yamashiro.

Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2026

LIC809 (FAS) - (06/04)

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