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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701301
Report Date: 07/10/2024
Date Signed: 07/12/2024 10:00:23 AM

Document Has Been Signed on 07/12/2024 10:00 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/
DIRECTOR:		VILLAMIL, EMMAFACILITY TYPE:
740
ADDRESS:738 CHESHIRE CT.TELEPHONE:
(209) 482-8943
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 6CENSUS: 2DATE:
07/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Gloria AndresTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 07/10/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff person, Gloria Andres, who was briefly interviewed at this time.
This LPA requested that the facility staff go ahead and contact the facility designated Administrator, Emma Villamil, to inform her that CCL was present at this time. The facility designated Administrator was unable to be present at this time for today's annual visit.
Current census was 2 residents.
It was learned that there were (2) residents under the care of hospice at this time.
It was learned that there were (2) residents receiving services through home health at this time.
It was learned that there was (1) resident diagnosed with dementia at this time.
Facility staff files were supplied by the facility designated staff person Gloria Andres. This LPA requested for the facility staff files at this time.
Tour of this facility was conducted.
Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Linen closet, located in facility hallway, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time.
Kitchen area was toured.
Kitchen drawers and cabinets were opened and reviewed. Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times.
Additional food storage units were observed to be present and functional at this time.
Laundry area, located in the garage area, was toured. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
Administrator certificate, #6031824740 for Emma Villamil, was observed to have an expiration date of 05/07/2024 at this time. It was learned that Emma Villamil was the only certified Administrator at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DIAMOND CARE HOME FOR SENIORS II
FACILITY NUMBER: 392701301
VISIT DATE: 07/10/2024
NARRATIVE
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Medication cabinet, located in the facility entry way closet, was observed to be locked and made inaccessible to the residents at this time.
First aid kit, located in a kitchen drawer, was reviewed. This LPA observed that it did contain all of the required components at this time.
Fire extinguisher, located next to the kitchen area, was observed to have been annually purchased by this facility designated Administrator. The receipt, attached to the fire extinguisher, was observed to have been purchased from Home Depot on 01/13/2023 at this time.
Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted.
A review of (2) facility resident files was conducted and noted on the following LIC 858.
A review of (1) facility staff file was conducted and noted on the following LIC 859.
The following forms and documents were requested to be updated and submitted into CCL:
  • LIC 308

  • LIC 400

  • LIC 500

  • LIC 610


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: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/12/2024 10:00 AM - It Cannot Be Edited


Created By: Charlie Yang On 07/10/2024 at 01:34 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: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [2] resident files diagnosed with dementia did not have an updated medical assessment which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2024
Plan of Correction
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The facility designated Administrator stated that all residents diagnosed with dementia will be scheduled with their licensed medical professional to undergo and complete an updated annual medical assessment. A statement of correction, along with a copy of the updated annual medical assessment, will be completed and submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/12/2024 10:00 AM - It Cannot Be Edited


Created By: Charlie Yang On 07/10/2024 at 01:34 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: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(6)(A)
Personnel Records
(A) For administrators this shall include verification that he/she meets the educational requirements in Section 87405(d) through (g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [1] facility Administrator certificate had expired on 05/07/2024 and in need of update and recertification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2024
Plan of Correction
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The facility designated Administrator stated that the required number of courses and hours will be scheduled and completed in a timely manner in order to update and recertify at this time. A statement of correction, along with proof of scheduled training courses and hours, 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
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Based on record review, the licensee did not comply with the section cited above in [1] out of [1] facility resident files did not contain all of the required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2024
Plan of Correction
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The facility designated Administrator stated that all facility resident files will be reviewed and updated to contain all of the required forms and documents. A statement of correction, along with copies of the updated forms and documents, 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: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024


LIC809 (FAS) - (06/04)
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