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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701301
Report Date: 12/11/2023
Date Signed: 12/12/2023 10:53:06 AM

Document Has Been Signed on 12/12/2023 10:53 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DIAMOND CARE HOME FOR SENIORS IIFACILITY NUMBER:
392701301
ADMINISTRATOR:VILLAMIL, EMMAFACILITY TYPE:
740
ADDRESS:738 CHESHIRE CT.TELEPHONE:
(209) 482-8943
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 6CENSUS: 4DATE:
12/11/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Emma VillamilTIME COMPLETED:
02:00 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
Unannounced Post Licensing visit conducted out at this facility on 12/11/2023 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator, Emma Villamil, at this time. A brief interview was conducted with the facility designated Administrator.
Current census was 4 residents.
It was learned that there were (2) residents under the care of hospice at this time. This facility does have an approved hospice waiver to be able to accept and retain up to (6) residents at any given time.
A tour of this facility was conducted.
Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Emma Villamil. Additional forms and documents were reviewed to make sure that the renewal process was initiated prior to the certificate expiration date of 05/27/2024 with certificate # 6031824740.
Kitchen area was toured. Cabinets and drawers were reviewed.
Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe an additional food storage unit which was present and functional at this time in the garage area.
A tour of the dining area, living area, and all other areas intended for resident use was conducted.
Medication cabinet, located in the hallway closet, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated Administrator at this time. This medication cabinet was observed to be locked and made inaccessible to the residents at this time.
A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Linen closet, located in the hallway, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
Garage area was toured. This area housed additional furniture and supplies for the facility residents.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DIAMOND CARE HOME FOR SENIORS II
FACILITY NUMBER: 392701301
VISIT DATE: 12/11/2023
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
26
27
28
29
30
31
32
Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Fire extinguisher, located in facility kitchen area, was observed to have been annually purchased from the local hardware store on 01/12/2023, with receipt attached, and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.

A review of (4) facility resident files was conducted and noted on the LIC 858.
A review of (4) facility personnel files was conducted and noted on the LIC 859.

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/12/2023 10:53 AM - It Cannot Be Edited


Created By: Charlie Yang On 12/11/2023 at 01:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DIAMOND CARE HOME FOR SENIORS II
FACILITY NUMBER: 392701301

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above since the hot water that was reviewed was measured at a temperature of 128.5 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2023
Plan of Correction
1
2
3
4
The facility designated Administrator stated that the hot water heater will be turned down immediately. Hot water temperatures will be taken, for the next (7) days, and documented as such daily. A statement of correction, along with (7) days worth of hot water temperature recordings, will be completed and submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/12/2023 10:53 AM - It Cannot Be Edited


Created By: Charlie Yang On 12/11/2023 at 01:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DIAMOND CARE HOME FOR SENIORS II
FACILITY NUMBER: 392701301

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that all personnel files were incomplete missing required updated forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2023
Plan of Correction
1
2
3
4
The facility designated Administrator stated that all facility personnel files will be updated to contain all required forms and documents. A statement of correction, along with scanned copies of the updated personnel files, will be completed and submitted into CCL by the due date.
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that all resident files were incomplete missing required updated forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2023
Plan of Correction
1
2
3
4
The facility designated Administrator stated that all facility resident files will be updated to contain all required forms and documents. A statement of correction, along with scanned copies of the updated resident files, will be completed and submitted into CCL by the due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4