306004757-7-26-2022-22-AS-KSGH-CGPQEK-20220726120628

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004757
Report Date: 07/26/2022
Date Signed: 07/26/2022 12:06:42 PM

Document Has Been Signed on 07/26/2022 12:06 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	DIAMOND SENIOR CARE		FACILITY NUMBER:	306004757
ADMINISTRATOR:	ADELA ALBU		FACILITY TYPE:	740
ADDRESS:	13581 DIAMOND HEAD DRIVE		TELEPHONE:	(714) 508-3100
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY:	6	CENSUS: 6	DATE:	07/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Adela Albu, Administrator Stephanie Ilk, caregiver Ghergina Lupu, caregiver		TIME COMPLETED:	12:30 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	On 07/22/2022 at 9:45pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by Stephanie Ilk and Ghergina Lupu, caregivers. Administrator Abela Albu was notified by telephone and arrived later to assist with the visit. One of the two staff present is adequately cleared and associated to the facility while the second one is cleared but is found to have been separated by mistake. LPA provides consultation and indicates that the staff member in question will need to be associated back to the facility. At approximately 10:05am, LPA accompanied by caregiver toured the physical plant of the facility. There are currently six (6) residents in care, one (1) of which is receiving hospice care. Residents are observed relaxing in their respective bedrooms and appear clean and well taken care of. The six (6) bedrooms include all necessary components. The three (3) bathrooms are equipped with grab bars and slip mats. During the visit, LPA observes cleaning supplies left accessible in one of the shared bathrooms as well as in one en-suite bathroom. Caregiving staff put cleaning supplies away during the visit. The facility is clean, sanitary and free of odors in all areas inspected. Physician orders for postural supports were found to be present for all residents with bed rails. Sharp instruments are stored in a kitchen drawer with a functional key lock. LPA observed a sufficient supply of food and water. The central storage of medication is located in a locked cabinet next to the kitchen. Cleaning supplies are secured in two cabinets located in the laundry room. A sufficient supply of linen is observed. LPA observed required department postings and COVID precaution posters on display. Facility has an adequate supply of PPE available. CONTINUED ON LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

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 07/26/2022 12:06 PM - 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: DIAMOND SENIOR CARE	FACILITY NUMBER: 306004757
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(f)

The California Code of Regulations Section 87705(f) relative to the care of persons with dementia posits that "The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Cleaning supplies and gardening shears observed by LPA not stored in a secure and locked location
	Deficient Practice Statement
1 2 3 4	Based on the observations amde during the visit, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/27/2022
	Plan of Correction
1 2 3 4	Cleaning supplies as well as any other item that could constitute a danger to the residents diagnosed with dementia will be stored securely by the licensee.

Type B

Section Cited

CCR

87458(a)

Section 87458(a) of the California Code of Regulations indicates that "the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year." This requirement is not met as evidenced by: Medical Assessment were found to be outdated in four of the five resident files reviewed during the visit.
	Deficient Practice Statement
1 2 3 4	Based on the record review conducted during the visit, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/26/2022
	Plan of Correction
1 2 3 4	The licensee will ensure that Medical Assessments for the four residents are conducted and updated within the next month.

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: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: DIAMOND SENIOR CARE	FACILITY NUMBER: 306004757
	VISIT DATE: 07/26/2022

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CONTINUED FROM FORM LIC809

LPA toured the outside of the facility and observed outdoor furniture in a shaded area on the patio for the enjoyment of residents and visitors. Gardening shears are observed to be left out and put away by caregiving staff during the visit. The two perimeter gates are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Based on the observations made during today’s visit, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report along with appeal rights was provided and left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

LIC809 (FAS) - (06/04)

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