331881330-8-28-2023-18-AS-JROO-CV5N9A-20230828101538

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881330
Report Date: 08/28/2023
Date Signed: 08/28/2023 10:16:53 AM

Document Has Been Signed on 08/28/2023 10:16 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	DIAMOND COTTAGE		FACILITY NUMBER:	331881330
ADMINISTRATOR:	BRAVO, ARNOLD		FACILITY TYPE:	740
ADDRESS:	30778 DROPSEED DRIVE		TELEPHONE:	(951) 926-2398
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92563
CAPACITY:	6	CENSUS: 5	DATE:	08/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Caregiver Anthony Mike Vito		TIME COMPLETED:	10:30 AM

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On 8/28/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Caregiver Anthony Mike Vito who was informed of the purpose of visit. During the visit, five (5) residents and two (2) staff present.

The facility is approved to care for six (6) non-ambulatory residents of which one (1) may be bedridden. The facility has a hospice waiver for 6. The facility is made up of four (4) resident bedrooms, two (2) bathrooms, a kitchen, dining room, living/family area, laundry room and garage.

During the visit, LPA observed the following:

Kitchen: LPA observed kitchen to be clean. Food is stored in a safe and healthful manner. The facility has a 2-day supply of perishable food items and 7-day supply of non-perishable food items. Sharps are secured in a locked kitchen drawer.

Dining and Living room: LPA toured the dining and living/family room area. LPA observed areas to be clean and furniture in good condition. LPA observed residents watching television in the living room and sleeping in their rooms. Fire extinguisher is charged and mounted in the dining room.

Hallway: LPA observed hallway to be clean with no pathway obstruction. Carbon monoxide and smoke detector were tested and functioning properly.

Continued on LIC809-C..

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DIAMOND COTTAGE	FACILITY NUMBER: 331881330
	VISIT DATE: 08/28/2023

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Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a kitchen cabinet. LPA reviewed physical medications for two residents and did not observe any discrepancies.

Bedrooms: Resident bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Bathrooms have a working toilet, wash basin, and were equipped with a grab bar in the shower. The hot water temperature measured at 116-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the residents in care.

Laundry/Garage: LPA observed laundry room and garage to be clean. Washing machine and dryer are in good repair. Cleaning solutions and chemicals are secured in a locked cabinet in the laundry room. Emergency food supplies, water and incontinent supplies are stored in the garage.

Records: Staff present have a criminal record clearance on file and are associated to the facility. Staff training is up to date.

Yard/Outside Area: Covered patio seating is available for residents. A brick wall secured the entire backyard. All outdoor pathways were free of obstructions. No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

During today's visit, LPA did not observe any deficiencies. An exit interview was conducted, and a copy of this report was reviewed and provided to Caregiver Vito.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

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