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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603604
Report Date: 11/18/2022
Date Signed: 11/18/2022 11:06:41 AM

Document Has Been Signed on 11/18/2022 11:06 AM - 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:A BELOVED HOME OF DIAMOND BARFACILITY NUMBER:
198603604
ADMINISTRATOR:DUONG, MY MYFACILITY TYPE:
740
ADDRESS:454 S ROCK RIVER RDTELEPHONE:
(626) 899-6999
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: DATE:
11/18/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:My My Duong- ApplicantTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) V. Maldonado made an announced visit at the facility for the purpose of conducting the Pre-Licensing inspection. LPA Maldonado met with applicant My My Duong and explained the purpose for the visit. The facility is a one-story home, located in a residential area. The facility will be licensed to serve the elderly, ages 60 and over. It is approved for (6) non-ambulatory residents, of which (1) may be bedridden in room# 3 only, with an approved hospice waiver for (6) and a dementia care plan.

The home consists of (5) bedrooms, (2) bathrooms, a kitchen, living room, dining room, laundry room, caregiver break room, a shaded patio in the back yard, and an attached garage. LPA conducted a tour of the physical plant with licensee My My Duong and observed the following: All resident bedrooms had the required furniture such as bedding, linens, closet, additional storage space, chairs, and lamps. Bedroom# 1 has a fireplace that is not in use and inaccessible by a fire screen. Both bathrooms had the required grab bars and non-skid mats. The water temperature was tested and measured at 108*F, which is within the required 105*F-120*F, per Title 22 Regulations. Additional linens were observed to be sufficient and in good condition. The laundry room was observed to be locked, with cleaning supplies/toxins/laundry supplies stored inside and inaccessible. The washer and dryer are operational and in good repair. There is a door at the end of the laundry room that leads to the garage. The garage will be used for additional storage and will remain locked and inaccessible to residents in care. The required signage was posted in the living room area, readily available for staff/residents/visitors to view. A copy of the Plan of Operations, Dementia Care Plan, and Hospice Waver Plan were maintained in the closet with the files. Auditory devices were observed at every entry/exit and were operational at the time of the visit. All entrances, exits, and walkways were observed to be free of debris, obstructions, and hazards. There are exit signs posted above every exit way in the facility and and signs with arrows pointing to the exit ways. The kitchen was observed to have the required food, flatware, utensils, and cups.

(Report Continued LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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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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: A BELOVED HOME OF DIAMOND BAR
FACILITY NUMBER: 198603604
VISIT DATE: 11/18/2022
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 All equipment in the kitchen was observed to be operational and in good repair. All sharps were observed to be in a drawer in the kitchen inside a lockbox. Staff/resident files were observed to be complete and will be maintained/locked in a closet in the hallway. Resident medications will also be centrally stored, locked and inaccessible in a hallway closet. The First Aid Kit, First Aid Manual, and emergency lighting were observed stored in the hallway closet where medications will be stored. The First Aid Kit had all of the required items such as bandages, gauzes, scissor, tweezers and a thermometer. The smoke/carbon monoxide detectors were observed to be interconnected and were tested and operational at the time of the visit. Several fire extinguishers were observed throughout the facility to be have recent inspections and be fully charged. An operating telephone was observed and was operational in the facility for resident use.

During the pre-licensing inspection, LPA did not observe items which do not comply with applicable laws and regulations. Applicant My My Duong completed Comp III Orientation.

The physical plant has been cleared.

An exit interview was conducted, and a copy of this report has been provided to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with their assigned CAB Analyst.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC809 (FAS) - (06/04)
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