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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002792
Report Date: 04/29/2026
Date Signed: 04/29/2026 11:38:32 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/05/2025 and conducted by Evaluator Marisa Chiarelli
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20251205162047
FACILITY NAME:DIAMOND RESIDENTIALFACILITY NUMBER:
455002792
ADMINISTRATOR:MONISMITH, CRYSTALFACILITY TYPE:
735
ADDRESS:16981 CATALINA WAYTELEPHONE:
(530) 215-1607
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:4CENSUS: 4DATE:
04/29/2026
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Administrator Crystal MonismithTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
 Neglect/Lack of Care and Supervision
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 04/29/2026, Marisa Chiarelli, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 12-09-25. LPA Chiarelli, met with Crystal Monismith, Administrator, and explained the purpose of the visit.

During the interview process, professional medical staff, the administrator, former administrator, two care staff persons and three residents were interviewed. The following documents were received and reviewed: Staff schedule, Staff phone numbers, Admission agreement, IPP, Physician Report, Medical records, MAR, Care plan for restricted health condition, staff training and staff daily logs.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Marisa Chiarelli
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 59-AS-20251205162047
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DIAMOND RESIDENTIAL
FACILITY NUMBER: 455002792
VISIT DATE: 04/29/2026
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
Medical record review revealed on 11/24/2025, resident one, (R1) presented to the Emergency Department (ED) with suspected complications from a chronic suprapubic catheter. Medical records suggest R1 experienced stomach pains and her catheter was not sufficiently draining in the days leading to her hospitalization. R1, who had a history of Urinary Tract Infections (UTIs) experienced irregular bladder wall thickening, hematuria, and blood clots in her catheter resulting in her becoming septic and ultimately passing from cardiopulmonary arrest. Staff reported changing and cleaning R1’s catheter bag and lines twice daily per doctor’s directions.
Facility records show that every catheter change and cleaning was marked as completed for
the month of November (2025). Urologic records confirm that staff took R1 to her monthly
medical appointments in the months leading up to her passing. Furthermore, the medical
records reflect that staff consulted with medical staff after observations of light bleeding into the
catheter bag and issues with draining which were addressed or dismissed by medical staff.
There is insufficient evidence to suggest that neglect or lack of care and supervision led the
development of an infection and subsequent death.

Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Marisa Chiarelli
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2