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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804100
Report Date: 01/27/2025
Date Signed: 01/27/2025 12:23:33 PM

Document Has Been Signed on 01/27/2025 12:23 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:DIAMOND CARE HOMEFACILITY NUMBER:
486804100
ADMINISTRATOR/
DIRECTOR:		ADONA, THELMAFACILITY TYPE:
735
ADDRESS:286 BEGONIA BLVDTELEPHONE:
(707) 718-4501
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 4DATE:
01/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Staff Member, Sandra Martinez, and Administrator, Thelma AdonaTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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At approximately 9:20AM, Licensing Program Analysts (LPAs) Felias and Magdaleno, arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Sandra Martinez. Administrator, Thelma Adona, arrived during visit at approximately 9:45AM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance for 6 ambulatory, of which 2 can be non-ambulatory, and a total capacity for 6 Clients. Upon arrival, LPAs was informed that there were 4 clients in care, and 1 staff member on-site.

LPAs reviewed Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPAs conducted a walk-though of the facility with Administrator. LPAs observed the following: Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a one story building with 3 Client bedrooms, 1 staff room, 2 bathrooms, and common areas. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for client use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.

LPAs reviewed staff and client files, client medication, and P&I monies. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. P&I monies were documented, secure and not commingled. Medication was observed to be centrally stored and secure. Administrator's Certificate for Thelma Adona (7002581735) was current with an expiration date of 10/13/2025. Fire extinguishers were last inspected June 2024. Smoke and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted December 2024.

Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: DIAMOND CARE HOME
FACILITY NUMBER: 486804100
VISIT DATE: 01/27/2025
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Continued from LIC809

LPAs requested the following documents to update facility file:
  • Affidavit regarding Client/Resident Cash Resources (LIC400)
  • Updated Surety Bond (LIC402)
  • Designation of Facility Responsibility (LIC308)
  • Emergency Disaster Plan (LIC610E)
  • Updated Personnel Report (LIC500)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate


Documents to be submitted to CCL by due date of 2/27/2025.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC809 (FAS) - (06/04)
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