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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540127
Report Date: 11/06/2024
Date Signed: 11/06/2024 03:36:10 PM

Document Has Been Signed on 11/06/2024 03:36 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:DIAMOND LODGEFACILITY NUMBER:
380540127
ADMINISTRATOR/
DIRECTOR:
JACOB, ANNIE M.FACILITY TYPE:
735
ADDRESS:20 ARLINGTON STREETTELEPHONE:
(415) 285-0688
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94131
CAPACITY: 23CENSUS: 21DATE:
11/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Pilar RodriguezTIME VISIT/
INSPECTION COMPLETED:
03:50 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 11/06/2024, Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced annual inspection. LPA met with staff member, Pillar Rodriguez and Administrator, Annie Jacob, joined shortly thereafter. LPA explained the purpose of the visit.

The ground floor had storage room, laundry room, bathroom, staff room, and garage. The second floor had 6 bed rooms, dinning hall, kitchen, 4 bathrooms, office and staff room. The third floor had staff room, kitchen, social hall, 4 bathrooms, and 7 bedrooms.

Backyard was fenced, secured, and in good condition. All outdoor and indoor passageway were free and clear of obstruction. No accessible bodies of water or fire safety hazards observed.

Kitchen was inspected, sufficient supply of food observed. Infection control practices reviewed. Medications, toxins and sharps stored appropriately and inaccessible to clients, a comfortable temperature was maintained, hot water temperature inspected to be compliant, furnishing and lighting was sufficient for comfort and safety.

Carbon monoxide detector and smoke detector system inspected and met the requirements. fire extinguisher checked and fully charged. Facility has a written emergency disaster plan. Licensee has at least one completed first aid kit located in the office.

Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed.

No Deficiencies cited. Report reviewed and discussed with Annie Jacob.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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