486804087-1-23-2024-21-AS-VBEI-CZTTPU-20240125135451

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804087
Report Date: 01/23/2024
Date Signed: 01/23/2024 09:06:16 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/27/2023 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20231127152520

FACILITY NAME:	PRECIOUS DIAMOND FAMILY HOME		FACILITY NUMBER:	486804087
ADMINISTRATOR:	LEE, ZINA		FACILITY TYPE:	735
ADDRESS:	733 5TH STREET		TELEPHONE:	(707) 888-8139
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94590
CAPACITY:	5	CENSUS: 4	DATE:	01/23/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Maria Ortega		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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9

Personal Rights
Uncleared individuals allowed in facility
Neglect/lack of supervision
Drugs being sold out of the facility

INVESTIGATION FINDINGS:

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5
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Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. This investigation included site visits, interviews with staff, client, witnesses, and review of pertinent documents and resulted in the following determinations: Complainant alleges S1 has hit client(C1) and is disrespectful to clients, that staff neglect the clients, that drugs are sold out of facility and that uncleared adults frequent the facility; Staff from two State agencies (CCL & NBRC) have made 5 site visits to facility in past 60 days, 3 visits unannounced, and at no time were uncleared adults or illegal drugs present and clients were observed to be clean and appropriately dressed; food supply adequate; C1 was interviewed at neutral location and indicated satisfaction with the placement and no fear of S1; Day Program Caregiver was interviewed and stated S1 displays no signs typically associated with abuse and looks forward to returning to facility. Although the allegations may be true, based on statements and documents, there is not a preponderance of evidence to prove or, disprove, allegations. Therefore, the complaint is UNSUBSTANTIATED. Report left.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/27/2023 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20231127152520

FACILITY NAME:	PRECIOUS DIAMOND FAMILY HOME		FACILITY NUMBER:	486804087
ADMINISTRATOR:	LEE, ZINA		FACILITY TYPE:	735
ADDRESS:	733 5TH STREET		TELEPHONE:	(707) 888-8139
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94590
CAPACITY:	5	CENSUS: 4	DATE:	01/23/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Maria Ortega		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

1
2
3
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5
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7
8
9

Medications are not administered in a timely fashion

INVESTIGATION FINDINGS:

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5
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11
12
13

Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. This investigation included site visits, interviews with staff, client, witnesses, and review of pertinent documents and resulted in the following determinations: Client (C2) has medical condition requiring staff to clean and apply medication to an area of C2’s body; Complainant alleges that staff have not provided proper care and that medication has not been administered timely; Inspections by staff from this and another State agency have observed C2 and found C2 to be in a clean condition; a review of the November, 2023 Medication Administration Record for C2 indicates that on 2 out of 30 days ( 11/29 & 11/30 ) the medication was not administered as ordered by physician to C2. Based upon the statements and documents, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20231127152520

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PRECIOUS DIAMOND FAMILY HOME	FACILITY NUMBER: 486804087
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/26/2024 Section Cited CCR 80075(b)(5)(B)	1 2 3 4 5 6 7	80075(b)(5)(B) Health Related Services. Once ordered by the physician the medication is given according to the physician's directions. ***This requirement not met as evidenced by: MAR for C2 indicates hydrocortisone crème was not administered as ordered	1 2 3 4 5 6 7	Administrator will provide refresher training to all staff who administer medications on the requirements of 80075 and will submit proof of training by POC date in order to clear the deficiency.
	8 9 10 11 12 13 14	on 2 out of 30 days (11/29 & 11/30). This posed an immediate risk to C2’s health.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC9099 (FAS) - (06/04)

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