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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804100
Report Date: 01/03/2023
Date Signed: 01/03/2023 03:51:45 PM

Document Has Been Signed on 01/03/2023 03:51 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:DIAMOND CARE HOMEFACILITY NUMBER:
486804100
ADMINISTRATOR:ADONA, THELMAFACILITY TYPE:
735
ADDRESS:286 BEGONIA BLVDTELEPHONE:
(707) 718-4501
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 5DATE:
01/03/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Thelma Adona, ApplicantTIME COMPLETED:
03:33 PM
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Licensing Program Analyst (LPA) Karina Canela conducted a Change of Ownership pre-licensing inspection on 01/03/2023. LPA met with Applicant Thelma Adona, who will be the Administrator when the facility is approved for licensure. Staff Sandra and Griselda were also present. The facility has a fire clearance approval from the Fairfield Fire Department for 4 ambulatory and 2 non-ambulatory (in bedroom #3 only) for a total capacity 6. The facility does not have approval from the Fairfield Fire Department to accept or retain bedridden residents. Facility will operate with a live-in staff and Licensee will ensure sufficient staffing at all times. The applicant has not submitted any waivers at this time. The facility does not have approval to lock the perimeter, if applicant wishes to do so they understand they must submit a waiver to Community Care Licensing and obtain approval from the Fire Department.

During today’s visit LPA observed the following items:
· COVID-19 symptom screening documentation
· Lockable separate cabinets for medications, toxins, and knives.
· All exits were unobstructed
· 7 smoke detectors & 1 carbon monoxide detector, which were tested & observed to be operational
· Complete first aid kit, bathroom night-lights, and flashlights for emergency lighting
· Supply of linens, paper products, and hygiene supplies available
· Grab bars and non-slip mats in 2 of 2 bathrooms.
· 2 of 2 Fire Extinguishers charged and serviced 07/06/2022
· Required furnishings in all 3 of resident bedrooms
· Quarterly emergency disaster drill
· Administrator Certifications; Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, and visitor policy).

Pre-licensing is complete and this facility has no deficiencies.

The Component III Orientation was completed during today's visit. LPA will submit the pre-licensing application report to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2023
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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