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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608378
Report Date: 11/30/2023
Date Signed: 11/30/2023 04:07:22 PM

Document Has Been Signed on 11/30/2023 04:07 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:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Helen Torres, AdministratorTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to caregiver staff Virginia Villacorte. Administrator Helen Torres arrived shortly after. There are currently 4 elderly residents 60 years and older residing in the facility. Twelve 12 (CARE) tool domains were utilized during the inspection.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed Staff are no longer wearing masks or screening visitors. A visitor sign-in station is still in place. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan.


Operational Requirements:
  • A current Plan of Operation was reviewed.
  • The facility has a Dementia Waiver in place. A Hospice Waiver for 6 is approved.
  • Facility has a fire clearance for 6 non-ambulatory adults 60 and over.
  • Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 6/2/2024.
  • A surety bond is not applicable. Facility does not handle resident's money.


***Narrative continues next page.****
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/30/2023
NARRATIVE
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Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential neighborhood that is licensed for six (6) non- ambulatory residents. The facility consists of (3) resident bedrooms, (1) staff room, (2) bathrooms, living room, dining room, kitchen, and attached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. Exit doors are free of any obstruction.
  • Kitchen drawers containing knives/sharp objects were unlocked. Citation was issued.
  • The facility has one (1) fully charged fire extinguisher, fire pull alarm, and fire sprinklers.
  • Water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. Water temperature ranged between 119.3 DF - 126.7 DF. Citation was issued.

Staffing:
  • A total of 5 caregiver staff provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificates expires 4/23/2024.
  • Personnel files/training were reviewed. Proof of staff training, health clearance, criminal background clearance and 1st Aid/CPR training was observed in staff files.

Resident Records/Incident Reports:
  • A total of four (4) resident files were reviewed. Files contained admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information.
  • RCFE complaint poster and Personal rights were observed posted.

Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed. Minimal activities are in place and the facility does not have a Resident Council.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
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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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FOUR DIAMONDS
FACILITY NUMBER: 197608378
VISIT DATE: 11/30/2023
NARRATIVE
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Food Service:
  • Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
  • Physician orders for modified diets are in place.
  • Sanitation practices and kitchen cleanliness was observed.

Incident Medical and Dental:
  • Four (4) centrally stored resident medications/30-day supply of medications were reviewed. Medication errors were observed. In addition, unlocked resident and staff medications were observed in a kitchen cabinet. Citation was issued.
  • Medical and dental transportation is provided by family members and 3rd party transportation services.

Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610D was posted, but the revised required form has not been developed.
  • The last emergency disaster drill was conducted on 10/5/2023.

Residents with Special Health Needs:
  • No residents are receiving home health services. One (1) resident is enrolled in palliative care. No postural support physician orders are on file.
  • Full bed rails for mobility assistance were observed in resident beds, but residents are not enrolled in hospice. Citation was issued.
  • Individual Service Plans and Appraisals were not observed in resident files.
  • No residents have prohibited health conditions.

Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Administrator Helen Torres. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 11/30/2023 04:07 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/30/2023 at 02:52 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: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in that Staff (S2's) medications pills and R3's Cholestyramine Light Powder were unlocked in a kitchen cabinet, and R2's Betamethasone Dipropionate Lotion & Hydrocortizone Cream were unlocked in the living room recliner, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Administrator agrees to submit a written plan of correction that states how the deficiency was corrected. In addition, all staff shall receive Title 22 Incidental Medical and Dental Care Services regulation training. Submit proof of training by tomorrow.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that R1's Quetiapine Fumarate 25 mg is a PRN med, but is being given as a routine noon medication, and the physician order for Vitamin C is 500 mg, but 1000 mg is being given, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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4
Administrator agrees to:
1. Submit proof of staff training.
2. Submit a written plan that addresses centrally stored record keeping/inventory protocols.
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: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/30/2023 04:07 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/30/2023 at 02:52 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: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section above in that R1 OTC Calcium 1200 mg, B-12 (5000 mg), and Vitamin K do not have a physician order and it is not documented on Centrally Stored Records, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Administrator agrees to:
1. Obtain a physician order for R1's OTC medications
2. Update Centrally Stored Records
3. Conduct staff training and submit proof to LPA by tomorrow.
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that residents (R1, R2, & R4) have full bed rails without a physician order. R1 is receiving palliative care and R2 & R4 are not enrolled in hospice care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Administrator agrees to:
1. Remove the full rails from residents beds and obtain by tomorrow a physician order for half bed rails for residents R1, R2, & R4.
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: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/30/2023 04:07 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/30/2023 at 02:52 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: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that LIC 610D Emergency Disaster Plan was not posted, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
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Administrator agrees to submit a copy of LIC 610D Emergency Disaster Plan.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 11/30/2023 04:07 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/30/2023 at 03:45 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: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
MAINTENANCE AND OPERATION
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in that the kitchen sink water temperature was 126.7 DF, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/24/2023
Plan of Correction
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Administrator agrees to conduct staff training and submit:
1. Hot water temperature log tested 3 times today and each shift tomorrow
2. Written plan and proof of staff training
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


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