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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608378
Report Date: 06/15/2022
Date Signed: 06/15/2022 01:53:46 PM

Document Has Been Signed on 06/15/2022 01:53 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:FOUR DIAMONDSFACILITY NUMBER:
197608378
ADMINISTRATOR:HELEN TORRESFACILITY TYPE:
740
ADDRESS:1926 TILLIE COURTTELEPHONE:
(626) 581-1695
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 4DATE:
06/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Helen Torres, AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza made an unannounced visit to investigate complaint control #: 28-AS-20220614122804 LPA discussed the purpose of the visit with Administrator Helen Torres and Assistant Administrator Daniel Hurtado.

  • File review of staff files was conducted. Staff (S1) began working at the facility yesterday June 14, 2022 and is cleared, but not associated; which poses an immediate health and safety risk to persons in care.
  • LPA observed 2 kitchen knives on the counter, 1 kitchen knife in the dish rack, and the knives/sharps drawer unlocked. The facility has one (1) Dementia resident in care; which poses an immediate health and safety risk to persons in care.

Deficiencies have been cited. See LIC 809D. Civil penalty was assessed.

Exit interview was held with Assistant Administrator Daniel Hurtado. A copy of this report and appeal rights were provided.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2022
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 06/15/2022 01:53 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/15/2022 at 01:15 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FOUR DIAMONDS
FACILITY NUMBER: 197608378

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2022
Section Cited
CCR
87355(c)(1)

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Criminal Record Clearance. A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department.A signed Criminal Background Clearance Transfer Request, LIC 9182 (Rev. 4/02).
This requirement is not met as evidenced by:
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Licensee shall ensure that all staff complete a criminal background transfer request and are associated to the facility prior to employment. Staff cannot return to work until they are associated to the facility.

Submit form LIC9182 by tomorrow's POC due date.
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Based on records reviews Staff (S3) is not associated to the facility. S1 began working at the facility yesterday June 14, 2022.This poses an immediate health and safety risk to residents in care.
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Type A
06/15/2022
Section Cited
CCR87705(f)(1)

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87705(f)(1) Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This poses and immediate health and safety risk to residents in care.
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Licensee shall ensure all sharps are locked and inaccessible to residents in care at all times.

Staff locked knives immediately.

****Cleared during the visit.
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Based on observation 2 knives were observed on top of the counter, 1 on the dish rack, and the sharps/knives drawer was unlocked. Pictures were taken.
This poses an immediate health and safety risk to residents in care.
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022


LIC809 (FAS) - (06/04)
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