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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701072
Report Date: 10/15/2021
Date Signed: 10/15/2021 03:22:08 PM

Document Has Been Signed on 10/15/2021 03:22 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 VILLAGE CARE HOMEFACILITY NUMBER:
342701072
ADMINISTRATOR:OMOAHOLO, ROXANNEFACILITY TYPE:
735
ADDRESS:8709 CRYSTAL RIVER WAYTELEPHONE:
(607) 592-1611
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 4CENSUS: DATE:
10/15/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Applicant Roxanne OmoaholoTIME COMPLETED:
03:25 PM
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Announced Pre-licensing visit made via to this facility on 10/15/2021, LPA Anthony Tuck was met by the Applicant,Roxanne Omoaholo, who was briefly interviewed by LPA.
It was learned that this facility will be licensed to serve up to (4) residents (all) ambulatory at any given time.
There were no residents in care during today's Pre-licensing visit.
Tour of the facility was conducted with applicant. Dining area, living area, and all other areas intended for resident use were toured and observed to be furnished and maintained in compliance at this time.
Kitchen area was toured. Cabinets and drawers were opened and reviewed by LPA Tuck along with the Applicant. Knives and other sharp utensils were observed to be locked in a cabinet to make them inaccessible to the residents at all times.
Food supply for 2-day perishable and 7-day nonperishable quantities were reviewed to make sure that this facility was in compliance at this time.
Medication cabinet, located in the hallway area, was toured. First aid kit was observed to be present and contained all required components at this time.
A tour of the (2) private resident bedrooms and 1 shared resident room was conducted.
Furnishings and furniture intended for use by the residents were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the resident bathrooms was conducted. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Nonskid mats were observed to be present and in compliance at this time.
Laundry area was toured. All cleaning agents and detergents were observed to be locked and made inaccessible at this time. Continued on LIC 809C...


SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Anthony Tuck
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2021
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: DIAMOND VILLAGE CARE HOME
FACILITY NUMBER: 342701072
VISIT DATE: 10/15/2021
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Linen closet, located in the hallway, was observed to contain a sufficient supply of towels and linens able to meet the needs of the residents at this time. An inspection of the transport vehicle was conducted for safety and transport of clients. A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time. Gate latches were reviewed and observed to be functional and allowed access for emergency response. All proper posters were posted on walls. All smoke detectors were operational, and the carbon monoxide detector was operational.

There was 1 deficiency observed during today's Pre-licensing visit. Facility did not have a residents rights council poster posted in the facility. Applicant will submit proof of correction to LPA by 10/18/2021.

Component III interview was conducted with the Applicant and completed during today's Pre-licensing visit.

Exit Interview held with Applicant Roxanne Omoaholo. A copy of this report was provided to the applicant upon conclusion of the visit. .
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Anthony Tuck
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC809 (FAS) - (06/04)
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