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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608378
Report Date: 10/03/2022
Date Signed: 10/03/2022 04:09:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/29/2022 and conducted by Evaluator Valeria Maldonado
COMPLAINT CONTROL NUMBER: 28-AS-20220929160124
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: 3DATE:
10/03/2022
UNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Samson Deles- Assistant House Manager & Shanelle Hurtado- RNTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are not wearing PPE.
Staff are not following the infection control practice as required.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made unannounced visit at the facility regarding the above-mentioned allegations. LPA Maldonado met with assistant house manager Samson Deles and explained the purpose for the visit. Shortly after, RN Shanelle Hurtado arrived at the facility and assisted with the visit.

During today's visit, LPA toured the facility with Samson and observed the following: the front of the home, the entrance, living room, dining room, kitchen, 3 resident rooms, 2 bathrooms, and live-in staff room. LPA also requested a copy of the staff/resident roster, reviewed files for Staff# 1-5 (S1-S5), and itnerviewed S1-S2.

Regarding allegation: Staff are not wearing PPE.
Upon arrival, LPA Maldonado met with S1 and observed S1 to not be wearing a face mask, as provided by Community Care Licensing Division (CCLD) gudiance.
(Report Continued on LIC809-C...)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20220929160124
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 DIAMONDS
FACILITY NUMBER: 197608378
VISIT DATE: 10/03/2022
NARRATIVE
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LPA asked S1 why a face mask was not in use, and S1 responded it was because S1 forgot to put it on upon LPA's arrival. S1 put on a face mask when LPA asked. As S2 arrived to the facility, appropriate PPE was observed to be worn. S2 was asked about the policy of staff wearing PPE in the facility, and admitted that S1 does not always wear face mask as S1 is live-in staff. LPA informed S1 and S2 that PPE must be worn by staff inside the facility at all times, as that is current CCLD and lcoal Department of Public Health (DPH) guidance.

Regarding Allegation: Staff are not following the infection control practice as required.
LPA Maldonado reviewed facility file and determined that a mitigation plan was submitted and approved on 06/04/21. Upon arrival at the facility, LPA was not screened for COVID-19 symptoms, until LPA asked S1 why a screening was not initiated. S1 stated that the screening was not initiated as S1 forgot, due to the LPA's unannounced visit. S1 was reminded that CCLD guidance is to screen all residents, visitors, and staff upon entry to the facility and upon return from any outing. LPA observed COVID-19 sign-age throughout the facility promoting mask wearing, hand washing, and social distancing. There was also sign-age on proper donning and doffing of PPE and choosing the right face mask. LPA observed the PPE supplies in the facility and had less than 30 day supplies available. LPA observed hand sanitizer available in all resident rooms, hand soap in the bathrooms, and paper towels for hand drying. LPA reviewed files for S1-S5 for required training and In-Service training regarding COVID-19 infection control practices. LPA observed 4 out of 5 staff files to be missing COVID-19 infection control practices training certification. LPA asked S1 and S2 for records of staff and residents daily symptom screenings and they stated records are not kept, however daily symptoms are checked for all residents.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found to be substantiated. California Code of Regulations, Title 22 are being cited on the attached LIC-9099D.

An exit interview was conducted with assistant house manager Samson Deles and RN Shanelle Hurtado. A copy of this report and appeal right were provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220929160124
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 DIAMONDS
FACILITY NUMBER: 197608378
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2022
Section Cited
CCR
87412(c)
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87412 Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.
This requirement was not met as evidenced by:
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Licensee will provide in-service training for COVID-19 infection control practices and other required training for current staff. Copies of training certificates, training material, and sign in sheet for in-service training on COVID-19 prevention will be faxed to LPA by the POC due date.
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Based on interviews, observations, and records review, it was determined the licensee failed to maintain personnel records verification of required staff training and updated COVID-19 training for all staff currently employed.
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Type B
10/07/2022
Section Cited
CCR
87470(c)(1)(C)(3)
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87470 Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee...(1) The Infection Control Plan shall include all of the following:(C)An Infection Control Training Plan. (3.)The description of initial and ongoing training...
This requirement was not met as evidenced by:
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Licensee will provide in-service training for COVID-19 infection control practices and other required training for current staff. Copies of training certificates, training material, and sign in sheet for in-service training on COVID-19 prevention will be faxed to LPA by the POC due date.
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Based on interviews, observations, and records, review, it was determined that the licensee who is also the infection preventionist has failed to provide ongoing training to staff regarding infection prevention of communicable diseases, including COVID-19.
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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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3