306005258-3-26-2025-22-AS-AMEL-DF5U36-20250326151301

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005258
Report Date: 03/26/2025
Date Signed: 03/26/2025 03:14:57 PM

Document Has Been Signed on 03/26/2025 03:14 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 2		FACILITY NUMBER:	306005258
ADMINISTRATOR/ DIRECTOR:	ANCA, NICOLAE		FACILITY TYPE:	740
ADDRESS:	13612 UTT DRIVE		TELEPHONE:	(714) 505-3885
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	03/26/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Ana Anca - Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:30 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 this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit for the purpose of conducting required annual. LPA was greeted and granted entry into the facility by Caregiver. Administrator Ana Anca arrived shortly. LPA and AD conducted a tour of the inside and outside of the facility, common areas, residents rooms, kitchen, and garage and observed the following: Structure. This is a one-story home. Facility is a 6- bedroom, 3-bathroom, one-story house with detached garage that is being used for storage. There is a back yard with a patio cover for the residents and a gated pool. LPA observed 3 staff and 5 resident present at the facility. The 5 residents bedrooms are spacious and will easily accommodate the residents’ furnishings. Lamps, chairs, linens, and storage for each residents bedroom inspected. Staff Bedrooms. LPA inspected the 1 staff bedroom. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 109.1 and 112.5 degrees. LPA inspected all rooms in the facility. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen drawer. Toxins: observed locked under the sink. Medications are locked in kitchen cabinet. First-Aid Kit and Activity Supplies: observed and available.

Alisa Ortiz	TELEPHONE: (714) 703-4084
Andrea Mendivil	TELEPHONE: 714-703-2738
	DATE: 03/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

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

FACILITY NAME: DIAMOND SENIOR CARE 2	FACILITY NUMBER: 306005258
	VISIT DATE: 03/26/2025

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LPA reviewed 4 employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records and all staff have a current First Aid certificate.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the Administrator and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025

LIC809 (FAS) - (06/04)

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