<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700609
Report Date: 05/18/2022
Date Signed: 05/18/2022 01:47:28 PM

Document Has Been Signed on 05/18/2022 01:47 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DIAMOND OAK GUEST HOMEFACILITY NUMBER:
342700609
ADMINISTRATOR:MASSAQUOI, MOHAMEDFACILITY TYPE:
740
ADDRESS:8632 DIAMOND OAK WAYTELEPHONE:
(916) 685-4099
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
05/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Niomi Woods, Facility ManagerTIME COMPLETED:
01:45 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
LPAs T. White and R. Campbell made an unannounced visit on this date to conduct a health and safety check. LPA met with Niomi Woods, Facility Manager.

Health and Safety check included overall safety of the facility including food supply, physical plant and staffing. The facility appears to have enough food for residents, staffing for the day shift was adequate.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1