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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603604
Report Date: 06/29/2023
Date Signed: 06/29/2023 09:11:04 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
06/23/2023 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230623154904
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: 5DATE:
06/29/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:My My Duong/AdministratorTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Facility yard is hazardous.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial visit to investigate the above allegation. LPA met with My My Duong/Administrator and discussed the purpose of today's visit.

During this investigation, LPA obtained a copy of the Resident and Staff Rosters, interviewed My My Duong/Administrator and conducted a tour of the front and back yards.

Allegation: Facility yard is hazardous. Per interview conducted, Administrator was unaware that it was the facility's responsibility to have the brush (downhill towards the freeway) cleaned/maintained until the Administrator received a call from the Fire Department. Per Administrator, Administrator was under the impression that the City of Diamond Bar handles the brush cleaning (down the hill towards the freeway). Per Administrator, the clean up of the back yard/hill has been scheduled.

Refer to LIC 9099C for the continuance of this report.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
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-20230623154904
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: A BELOVED HOME OF DIAMOND BAR
FACILITY NUMBER: 198603604
VISIT DATE: 06/29/2023
NARRATIVE
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Based on LPA's interview and tour, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. Refer to LIC 9099D.

Exit interview held and a copy of the report and appeal rights was provided to My My Duong.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20230623154904
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: A BELOVED HOME OF DIAMOND BAR
FACILITY NUMBER: 198603604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/04/2023
Section Cited
CCR
87303(a)
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Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by:
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Administrator to have the brush cleaned and maintain it clean at all times. Administrator to submit a written statement as to how Administrator will comply with this regulation and provide proof of correction (pictures) to LPA Irra by POC due date of 07/04/23.
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Administrator was unaware that it was the facility's responsibility to have the brush (downhill towards the freeway) cleaned/maintained until the Administrator received a call from the Fire Department.
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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: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3