306006252-3-7-2024-22-AS-RMAZ-D35VMV-20240307153410

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006252
Report Date: 03/07/2024
Date Signed: 03/07/2024 03:34:22 PM

Document Has Been Signed on 03/07/2024 03:34 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	DIAMOND MANOR 2		FACILITY NUMBER:	306006252
ADMINISTRATOR:	HAMAMA, HAFEEZ		FACILITY TYPE:	740
ADDRESS:	1631 W TEDMAR AVE		TELEPHONE:	(714) 502-0121
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92802
CAPACITY:	6	CENSUS: 4	DATE:	03/07/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Hafeez Hamama		TIME COMPLETED:	04:20 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) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at the facility was greeted and granted entry. A change of ownership application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (1) ambulatory, (4) non-ambulatory, and (1) bedridden residents was submitted to CCL on 10/25/22. Structure: The facility is a two-story house with an attached garage with 4 resident bedrooms, 1 staff bedroom, 2 full bathrooms, a living room, a dining room, a family room, and a kitchen on the first floor of the facility. The second floor is occupied by applicants and there are no resident bedrooms on the second floor. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with an exit walkway on both sides of the house with covered seating for the residents. Air/Heating: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: Bedrooms will accommodate 6 residents with 2 private rooms and 2 shared room accommodating two residents. Bedrooms Staff: Bedroom #5 designated for awake staff. Bathrooms: All bathrooms have a working toilet, wash basin, walk in shower. Linens & Hygiene Supplies: Adequate supply of linen stored in hallway storage. Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food serve for one week. Food Service: Adequate supply of 7-day non-perishable and 2-day perishables are stored in the kitchen. Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, were tested, and Continued on LIC809-C

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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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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 2	FACILITY NUMBER: 306006252
	VISIT DATE: 03/07/2024

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found operational. Appliances: Gas six-burner stove/grill, single oven, 2 refrigerator (kitchen & garage), microwave, washer, and dryer are clean and noted to be operational. Toxins: All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored and locked in garage. Water Temperature: Tested and recorded maintained at a comfortable temperature and the water temperature measures 105.9 Fahrenheit degrees in facility bathrooms. Medications, First-Aid Kit & Book: Medication and first aid kit/book are stored and locked in a storage cabinet located kitchen. Resident & Staff Files: Records will be kept locked in the medication cabinet. Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the residents’ use, commensurate with the plan of operation. Fire clearance: Was approved on 06/09/2023. Component III: Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities.

The applicant has met all pre-licensing requirements. LPA will submit notification to CAB in Sacramento for final review prior to license being issued.

Exit interview was conducted with applicant and a copy of this report was left with the applicant.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

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