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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508681
Report Date: 03/18/2022
Date Signed: 03/18/2022 01:09:33 PM


Document Has Been Signed on 03/18/2022 01:09 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:DIAZ RESIDENTIAL CARE HOMEFACILITY NUMBER:
410508681
ADMINISTRATOR:DIAZ, MARIA AND ESTELAFACILITY TYPE:
740
ADDRESS:438 CEDAR STREETTELEPHONE:
(650) 366-1154
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY:6CENSUS: 5DATE:
03/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Caregiver, Dominique VivienTIME COMPLETED:
12:30 PM
NARRATIVE
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On March 18, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Caregiver, Dominique Vivien and Licensee, Stella Diaz Calder and Administrator, Maria Diaz Vivien joined shortly thereafter. LPA explained the purpose of the visit. Upon arrival LPA observed the COVID signage posted at the front door. Administrator was able to provide LPA with screening log documentation for residents, staff, and visitors. LPA observed a dog barking in the facility which resulted to a resident yelling that the dog is loud.

LPA toured the facility and ground. LPA observed COVID signage throughout the facility. LPA observed the living room desk to have tools, sharps, and papers disheveled. LPA also observed a wooden gate on the living room floor. LPA Charitra observed 3 camera monitors in the living room. The cameras were capturing video surveillance of the resident's rooms. Administrator was not able to provide LPA with any written consent of resident's agreeing to video surveillance.

LPA observed 2 bathrooms at the facility. Bathrooms were equipped with paper-towels and liquid soap. LPA advised caregiver to not keep any hand-towels, bath-towels, or bar soaps in the bathroom and to ensure both bathrooms have a hand-washing sign. There are a total of 5 bedrooms in the facility (2 staff rooms, 3 resident rooms). There is one private room and two shared rooms, with beds 6ft apart or 3ft head-to-toe.

LPA observed 2 day perishable and 7 day non-perishable present. LPA Charitra observed the 30-day PPE supply. Medications, toxins stored appropriately and inaccessible to residents, and a comfortable temperature is maintained, lighting is sufficient for comfort. First aid kit was observed to be completed. LPA toured the kitchen and observed sharps drawer to be unlocked.

LPA requests the following forms to be sent to CCLD by 3/25/22:
  • LIC308 Designation of Administrative Responsibility
  • LIC500 Personnel Report
  • LIC400 Resident Cash Resources
  • Administrator Certificate
  • LIC610E Emergency Disaster Plan

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the Administrator; a copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
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 3


Document Has Been Signed on 03/18/2022 01:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: DIAZ RESIDENTIAL CARE HOME
FACILITY NUMBER: 410508681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2022
Section Cited

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Additional Personal Rights of Residents in Privately Operated Facilities: In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To have a reasonable level of personal privacy in accommodations
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Violation of this regulation is evidence by the facility using video surveillance in resident’s rooms without resident’s or resident’s responsible parties' consent. In addition, facility failed to follow Health and Safety Code regulation for Video Surveillance
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Type B
03/25/2022
Section Cited

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Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights…to be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Violation of this regulation is evidence by: 1) LPA observed dog in the facility barking upon LPAs arrival. 2) LPA observed resident yelling the dog is loud when facility dog kept barking.
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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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/18/2022 01:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: DIAZ RESIDENTIAL CARE HOME
FACILITY NUMBER: 410508681

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2022
Section Cited

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Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Violation of this regulation is evidence by: 1) LPA was not able to sit in the facility to write report. 2) LPA observed disheveled desk in the living room with papers, tools, tissue boxes, and masks. 3) LPA observed a wooden gate on the living room floor.
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Type B
03/25/2022
Section Cited

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Care of persons with dementia: The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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Violation of this regulation is evidence by: LPA observed kitchen drawer with knives to be unlocked. In addition, LPA observed a pair of scissors on the living room desk, accessible to residents.
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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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3