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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001354
Report Date: 03/25/2024
Date Signed: 03/25/2024 11:18:52 AM


Document Has Been Signed on 03/25/2024 11:18 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:DIAMOND MANORFACILITY NUMBER:
306001354
ADMINISTRATOR:LOPEZ, CORAZONFACILITY TYPE:
740
ADDRESS:15460 MARLBOROUGH CIRCLETELEPHONE:
(714) 486-2737
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:6CENSUS: 4DATE:
03/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Corazon Lopez, AdministratorTIME COMPLETED:
11:45 AM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted a case management visit for the purpose of citing a deficiency observed during the investigation of complaint reference # 22-AS-20240103133808. LPA was greeted and granted entry by facility staff after introducing himself and explaining the purpose of the visit.

During the investigation, multiple interviews confirmed that on an unspecified date, resident R1 had sustained a fall while being placed in a shower chair, either during or directly after toileting care was provided. The fall resulted in bruising which may have been amplified or increased by the fact that R1 was administered blood thinners prescribed by their physician. The fall incident was not reported to the Department at the time as required.

One Type B citation is issued on the attached form LIC809-D.

An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2024
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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Document Has Been Signed on 03/25/2024 11:18 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: DIAMOND MANOR
FACILITY NUMBER: 306001354

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2024
Section Cited
CCR
80061(b)(1)(D)

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The California Code of Regulations Section 80061(b)(1)(D) on Reporting Requirements states: “Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, (…) a written report (…) shall be submitted to the licensing agency within seven days(...).
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Licensee to review applicable regulations for reporting requirements and provide additional training to staff accordingly. The proof of staff training will be submitted to LPA by the plan of corrections' due date.
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(D) Any injury to any client which requires medical treatment.” This requirement was not met as evidenced by: Based on a review of records, no report was submitted on the fall R1 sustained. This constitutes a potential risk to the health, safety and personal rights of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2