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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804087
Report Date: 09/12/2024
Date Signed: 09/12/2024 03:45:26 PM

Document Has Been Signed on 09/12/2024 03:45 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PRECIOUS DIAMOND FAMILY HOMEFACILITY NUMBER:
486804087
ADMINISTRATOR/
DIRECTOR:		LEE, ZINAFACILITY TYPE:
735
ADDRESS:733 5TH STREETTELEPHONE:
(707) 643-9106
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 5CENSUS: 4DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Zina Lee (Administrator)TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an annual required inspection and met with Administrator Zina Lee. Annual fees are current. Contact information was reviewed.

LPA/staff toured the facility inside and outside and observed the following: the facility was clean and at a comfortable temperature with all exits free from obstruction. Client's rooms furnished per regulation. There was a supply of Linens, cleaners, hygiene products and paper products available. Bathrooms have grab bars and floor mats. However, toilet paper was observed stored in cabinet inside the bathroom. Per staff, they keep the toilet paper there due to client's behaviors. Water temperature in clients' bathroom measured at 110.7 degrees, which 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 locked in the staff office where it is inaccessible to clients in care. Fire Extinguishers were found to be last charged on September 2024. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. Cleaning products and other toxins are located in the locked laundry room and inaccessible to clients in care. Last disaster drill was conducted on August 2024. Medication and medication records were reviewed. Cash resources and their records were not reviewed, because the administrator did not have them in the facility. LPA will return to review cash resources at a different date. Food menu was not available (technical violation was issued).

Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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Document Has Been Signed on 09/12/2024 03:45 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 09/12/2024 at 03:28 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
, 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: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(j)
Safeguards for Cash Resources, Personal Property and Valuables
(j) Cash resources entrusted to the licensee and kept on the facility premises, shall be kept in a locked and secure location.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Administrator observation, interview and record review, the licensee did not comply with the section cited above due to administrator not having cash resources available at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Licensee agreed to have cash resources maintained at the premises. Licensee will submit a self-certification form (LIC9098) to CCL by POC due date to clear the deficiency.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Administrator observation, interview and record review, the licensee did not comply with the section cited above in four out of four clients admission agreements were updated upon licensure, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Administrator agreed to update all client's admission agreements and will submit a self-certification form (LIC9098) to CCL by POC due date to clear the deficiency.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


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: 09/12/2024
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Continued from LIC809...

At 2:00pm LPA initiated file review of four clients and three staff files. Admission agreements indicating the change of ownership have not been updated for all clients (C1, C2, C3 & C4). LPA/Administrator have discussed the importance of updating client's admission agreements upon licensure. One out of four clients do not have a medical assessment on file (technical violation is issued). All clients care plans were updated. Staff have CPR/1st aid certificates and training hours updated. One out of three staff (S1) no health screening on file including TB test (technical violation is issued). Administrator Certificate for administrator Zina Lee #6012974735 expires on 11/30/24.

Administrator agreed to provide the following documents by 9/27/24: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency Disaster Plan (LIC610E if there are changes) updated Surety Bond & control of property (lease agreement).

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Given.

Exit interview was conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
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