198603701-10-27-2025-28-AS-LHIS-DNMRKE-20251121120527

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603701
Report Date: 10/27/2025
Date Signed: 10/27/2025 01:22:31 PM

Unsubstantiated

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
10/23/2025 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20251023152139

FACILITY NAME:	DIAMOND BAR RCFE		FACILITY NUMBER:	198603701
ADMINISTRATOR:	JOHNNY HO		FACILITY TYPE:	740
ADDRESS:	1652 MAPLE HILL ROAD		TELEPHONE:	(909) 861-7430
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY:	6	CENSUS: 6	DATE:	10/27/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Shelly Yamashiro - Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff did not seek proper medical attention for resident.
Staff are not allowing resident to use the phone.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to
investigate the above allegations. LPA met with Gloria Estrobo, Caregiver and explained the purpose of
the visit. At 12:43pm, Administrator Shelly Yamashiro arrived and assisted LPA with the investigation.

The investigation consisted of the following: LPA obtained copies of the staff & resident rosters, and Resident #1 (R1)'s pertinent files such as: Identification/Emergency Information, Admission Agreement, Physician's report, Need/Services Plan, Discharge Summary notes, Sign in and out sheet (October 2025), Medication Administration Record (MAR) (October 2025) and Kaiser Permanente Discharge summary. LPA interviewed Staff #1 (S1) - Staff #3 (S3) and Resident #1 (R1) - Resident #2 (R2). LPA attempted to interview Resident #3 (R3) - Resident #6 (R6) but was unsuccessful due to their cognitive capacities. *****CONTINUED ON LIC9099-C*****

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20251023152139

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: DIAMOND BAR RCFE	FACILITY NUMBER: 198603701
	VISIT DATE: 10/27/2025

NARRATIVE

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The investigation revealed the following:

Allegation: "Staff did not seek proper medical attention for resident." It is alleged that R1 was complaining about being in pain due to swollen legs and a nurse visited but was unable to give R1 medication. (3) of (3) staff interviewed stated that R1 was admitted with lower extremity swelling on October 07, 2025. Staff stated that R1 has follow-up care from a Kaiser nurse twice a week and is now receiving care from a home health nurse two times a week, with the latest visit on 10/24/2025. Staff also stated that R1 was complaining about leg pain when R1 first arrived, and staff have assisted R1 by elevating their foot and informing the Administrator. Staff interviewed stated that when any resident is in pain, including R1, they attend to them right away, assess, document and report to the Administrator. R1-R2 stated that staff are kind, that they help them when they are in pain and assist with their medical needs. Documentation reviewed and interviews conducted do not corroborate this allegation.

Allegation: "Staff are not allowing resident to use the phone." It is alleged that the staff won’t allow resident to use the phone. (3) of (3) staff interviewed denied the allegation. S1 stated that they allow R1 to use their personal cell phone to call family members or friends. In addition, the facility has a working land line that residents can use if they want to. Interviewed residents cannot corroborate the allegation. R1 stated that they do not have their own cell phone, however the staff allow them to use the staff's personal phone to call family members or friends. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held and a copy of this report was provided to the Administrator, Shelly Yamashiro.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025

LIC9099 (FAS) - (06/04)

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