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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804087
Report Date: 08/29/2023
Date Signed: 08/29/2023 11:52:43 AM

Document Has Been Signed on 08/29/2023 11:52 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PRECIOUS DIAMOND FAMILY HOMEFACILITY NUMBER:
486804087
ADMINISTRATOR:LEE, ZINAFACILITY TYPE:
735
ADDRESS:733 5TH STREETTELEPHONE:
(707) 888-8139
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 5CENSUS: 4DATE:
08/29/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee, Zina LeeTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs), Farhaan Sarangi and Christi Coppo arrived announced at Precious Diamond Family Home for the purpose of conducting a Pre Licensing Inspection. LPA was greeted at the front door by Licensee, Zina Lee, and was granted access into the facility. Fire Clearance approved for 5 ambulatory. Licensee presented the LPA with the Administrators Certificate for Adult Residential Facility (Certificate #6012974735 with an expiration of November 30, 2024). First Aid Certificate expires on December 13, 2023.

LPAs, Licensee and Caregiver toured the one story facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. During the tour of the facility, LPA observed a visitor policy not posted (See LIC 9102-Technical Advisory). LPA educated the Licensee regarding posting the visitation policy where visitors and clients can observe it. Fire Extinguishers were found to be last charged on September 2022 at the time of the inspection. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. First Aid kit was inspected. LPA advised to replenish the First Aid Kit (See LIC 9102-Technical Advisory) Water temperature in 2 of 2 clients bathroom measured at 114 degrees and is within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. Knives and other hazardous items were locked and inaccessible to Clients in care. Medications are double locked in the staff office where it is inaccessible to clients in care. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Cleaning products and other toxins are located in the locked laundry room and inaccessible to Clients in care. There was a supply of Linens, cleaners, hygiene products and paper products available for Clients in care during the Pre Licensing Inspection. All bathrooms designated for Clients in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in Clients rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all Clients bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. (Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PRECIOUS DIAMOND FAMILY HOME
FACILITY NUMBER: 486804087
VISIT DATE: 08/29/2023
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LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + or any other infectious diseases in the facility. LPA discussed the Infection Control Plan with the Licensee. LPA discussed the Emergency Disaster Plan in detail. Licensee has a backup generator on order.

Component III was waived due to Licensee already being licensed.

Exit interview was conducted, and a copy of this report was given to the Licensee. LPA will forward this report to the assigned Application Analyst in our Department; The Application Analyst will notify the Applicant of the status of the application.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC809 (FAS) - (06/04)
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