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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608378
Report Date: 11/20/2025
Date Signed: 11/20/2025 02:06:40 PM

Document Has Been Signed on 11/20/2025 02:06 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: 6DATE:
11/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Daniel Hurtado, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced annual inspection visit. The purpose of the visit was explained to caregiver Virginia Villacorte. Assistant Administrator Daniel Hurtado and Shanell Hurtado arrived shortly after. The facility serves elderly residents ages 60 and older.

The following were observed/inspected:



Infection Control: The Infection Control Plan was reviewed and includes environmental cleaning and disinfection activities. Facility has sufficient Personal Protective Equipment.

Operational Requirements: A Dementia and hospice waiver for 6 residents and fire clearance for 6 non-ambulatory is approved. Facility does not handle resident resident's 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 6/2/2026.

Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood. 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. Smoke and carbon monoxide detectors were tested and are operational. The facility has one (1) fire extinguisher. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The facility has a 1st Aid Kit and Manual. Cleaning supplies, knives, and toxic substances are inaccessible to residents. Exit doors are free of any obstruction and there are no pools or large bodies of water. The last Emergency Disaster drill was conducted on October 2025.

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

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 11/20/2025
NARRATIVE
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Personnel Records/Staff Training: Administrator certificate expires 4/23/2026. Staff have criminal background clearance and training. Six (6) staff files were reviewed. Files had health clearance, and 1st Aid/CPR training. However, proof of staff training was not available for review.

Resident Records/Incident Reports: A total of six (6) resident files were reviewed. The majority of the resident files were missing required documents i.e. Pre-Admission Appraisal, ID and Emergency Information, Safeguards for property/valuables, and updated Physician's Reports/Medical Assessment. Medication Administration records are in place, but staff are not documenting daily.

RCFE complaint poster is posted in the main entryway of the facility.

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. Residents have modified diets.

Incident Medical and Dental: Centrally stored resident medications were reviewed. 30-day supply of medications was observed. Medical and dental transportation is provided by family. Resident (R6's) is missing 2 medication refills.

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

Residents with Special Health Needs: Two (2) resident receives hospice services and one (1) resident receives home health services. No residents have prohibited health conditions. Residents have half bed rails and/ full rails for mobility assistance.

Pursuant to Title 22, deficiencies were observed.



An exit interview was conducted with Assistant Administrator Daniel Hurtado. A copy of the report and appeal rights was issued.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/20/2025 02:06 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/20/2025 at 01:09 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: 11/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
1569.626(b)
Advertising for special care, special programming, or a special environment for elderly with dementia; training requirements. All residential care facilities for the elderly that advertise or promote special care, special programming, or a special environment for persons with dementia, in addition to complying with the training requirements described in Section 1569.625, shall meet the following training requirements for all direct care staff: (b) Eight hours of in-service training per year on the subject of serving residents with dementia.
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 proof of staff training was not available for review, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2025
Plan of Correction
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Licensee shall submit proof that all staff have received 8 hours of in-service training on the subject of serving residents with dementia.
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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/20/2025 02:06 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/20/2025 at 01:31 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: 11/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 above; resident (R6's) Tamsulosin .4mg & Tylenol have not been refilled, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2025
Plan of Correction
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Administrator shall:
1. Submit proof that R1’s medications will be obtained by tomorrow.
2. Submit by tomorrow a written plan that addresses centrally stored record keeping/inventory protocols, refill procedures, and facility auditing of medications.
3. Submit proof of staff training by 11/21/2025.
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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/20/2025 02:06 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/20/2025 at 01:31 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: 11/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

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 residents (R1- R5) are missing file documents i.e., Pre-Admission Appraisal, ID and Emergency Information, Safeguards for property/valuables, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2025
Plan of Correction
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Administrator shall submit copies of residents (R1- R5's) required file documents listed on LIC 811 provided.
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 their 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 because resident's R1, R2, & R3 do not have Pre-Admission Appraisals on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2025
Plan of Correction
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Administrator shall submit copies of R1, R2, and R3's Resident Appraisals.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/20/2025 02:06 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/20/2025 at 01:31 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: 11/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

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 R1's Medical Assessment dated 9/29/2025 is missing TB exam/ results, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2025
Plan of Correction
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Administrator shall submit proof that R1 received a TB exam/results.
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

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 R3's Physician's Report is dated 1/17/2024, R4's Physician's Report is dated 8/30/2024, R5's Physician Report is dated 5/10/2023 & R6's Physician's Report is dated 2/5/2024, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2025
Plan of Correction
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Administrator shall submit copies of R3, R4, R5, and R6's updated Medical Assessments.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2025


LIC809 (FAS) - (06/04)
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