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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608378
Report Date: 12/09/2024
Date Signed: 12/09/2024 12:58:47 PM

Document Has Been Signed on 12/09/2024 12:58 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/
DIRECTOR:		HELEN TORRESFACILITY TYPE:
740
ADDRESS:1926 TILLIE COURTTELEPHONE:
(626) 581-1695
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 5DATE:
12/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:17 AM
MET WITH:Helen TorresTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced annual inspection visit. The purpose of the visit was explained to caregiver staff Virginia Villacorte. Administrator Helen Torres arrived shortly after. The facility serves elderly residents ages 60 and older. A hospice and Dementia waiver is in place. It 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. Twelve (12) CARE tools domains were reviewed.

The following were observed/inspected:



Infection Control: The Infection Control Plan was reviewed. The facility has a supply of Personal Protective Equipment (PPEs).

Operational Requirements: A hospice waiver for 6 residents has been approved. A fire clearance for 6 non-ambulatory residents. Facility does not handle resident P & I monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 6/2/2025.

Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. The facility has fully charged fire extinguishers. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Facility has a fire pull-alarm and sprinklers. Room #3 has a toilet leak and walls are in disrepair.

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

Personnel Records/Staff Training: Administrator certificate expired 4/23/2024. Staff have criminal background clearance and training. Four (4) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 12/09/2024
NARRATIVE
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Resident Records/Incident Reports: A total of 5 resident files were reviewed. All files were missing required documents. R1 has a Physician Report that is for ARFs, R4 is a hospice resident whose file was missing a Physician's Report, Appraisals, Needs and Services Plan, and none of the files had pre-admission appraisals. Centrally stored medication records are in place.

RCFE complaint poster and Personal rights were observed posted.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility does not have a Resident Council.

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. All residents are on modified diets.

Incident Medical and Dental: Centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual.

Residents with Special Health Needs: Four (4) residents are receiving hospice services and two (2) residents receive home health services. Two (2) residents have a Dementia diagnosis. Full bed rails for mobility assistance were observed in hospice resident's rooms. No residents have prohibited health conditions.

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



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

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 12/09/2024 12:58 PM - It Cannot Be Edited


Created By: Noemi Galarza On 12/09/2024 at 10:04 AM
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: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic
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 the front door has a slip latch lock on the top of the door above the auditory alarm that was turned off, as well as a locking mechanism latch by the door handle, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2024
Plan of Correction
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Licensee/Administrator shall remove the door lock immediately as it poses a Fire Safety hazard. During the visit, staff arrived and removed the locking mechanisms.
Licensee shall train all caregiver staff. Submit proof by TOMORROW.
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: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


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Document Has Been Signed on 12/09/2024 12:58 PM - It Cannot Be Edited


Created By: Noemi Galarza On 12/09/2024 at 11:57 AM
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: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, all resident admission agreements have an Addendum that was not approved by CCL that states the refund policy as "No refund shall be given ...any and all payments made are considered monthly and never daily", which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2024
Plan of Correction
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Licensee/Administrator shall submit a written plan of correction that addresses the non-approved Addendum to the Admission Agreement. Additionally, all resident's responsible parties must be issued written notification that the Addendum that was originally issued is void.
Type B
Section Cited
CCR
87506(b)(13)
Resident Records
(b) Each resident's record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or the services he needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility is using and ARF Physician's Report form for R1 instead of an RCFE form and hospice resident (R4's) file is missing MD report and needs and services plan, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2024
Plan of Correction
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Administrator shall submit a copy of R1's updated Physician's Report, and Physician's Report and Service Plan for 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: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 12/09/2024 12:58 PM - It Cannot Be Edited


Created By: Noemi Galarza On 12/09/2024 at 11:57 AM
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: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that all resident files did not have pre-admission appraisals, only R5 has a resident appraisal, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2024
Plan of Correction
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Administrator shall ensure all resident files have Resident Appraisals. Submit copies of R1- R4's Resident appraisals.
Type B
Section Cited
CCR
87407
Administrator Recertification Requirements
(d) To apply for recertification prior to the expiration date of the certificate, the certificate holder shall submit to the Department’s Administrator Certification Section, post-marked on, or up to ninety (90) days before, the certificate expiration date:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that Administrator certificate expired 4/23/2024 and recertification documents were sent until 9/3/24,which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2024
Plan of Correction
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Administrator showed LPA Guardian proof that shows recertification is pending. Cleared during the visit.
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: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 12/09/2024 12:58 PM - It Cannot Be Edited


Created By: Noemi Galarza On 12/09/2024 at 12:20 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: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(I)
Oxygen Administration - Gas and Liquid
(b) In addition to Section 87611(b), the licensee shall be responsible for the following:
(3) Ensuring that the use of oxygen equipment meets the following requirements:
(I) Equipment shall be removed from the facility when no longer in use by the resident.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, licensee has 3 oxygen tanks that are no longer being used in the garage, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2024
Plan of Correction
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Administrator agreed to contact company for removal of oxygen tanks. Submit proof by tomorrow.
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, resident room #3 has a toilet leak and walls are in disrepair, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2024
Plan of Correction
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Submit picture proof of correction.
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: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


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