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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005258
Report Date: 03/25/2022
Date Signed: 03/25/2022 11:49:48 AM

Document Has Been Signed on 03/25/2022 11:49 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:DIAMOND SENIOR CARE 2FACILITY NUMBER:
306005258
ADMINISTRATOR:ANCA, NICOLAEFACILITY TYPE:
740
ADDRESS:13612 UTT DRIVETELEPHONE:
(714) 505-3885
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: 5DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Jefreylans Jakosalem - Caregiver
Ana Anca - Administrator		TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Diamond Senior Care 2. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Caregiver Daisyree Arino. Caregiver Jefreylans Jakosalem was also present. Administrator (AD) Ana Anca arrived later during LPA's visit. The facility is licensed for 6 non-ambulatory residents of which 1 may be bedridden. The facility has a Hospice waiver for 2 residents. There are currently 5 residents living in the facility. The last emergency disaster drill was conducted on November 16, 2021. LPA Velazquez observed Caregiver Jakosalem did not appear on the Facility Personnel Report Summary. AD Anca was informed and is working to ensure Caregiver Jakosalem is properly associated to the facility.

At 10:28 AM LPA Velazquez conducted a tour of the physical plant along with Caregiver Jakosalem. The 1 story home consists of 5 resident bedrooms with 2.5 bathrooms and 1 staff bedroom. The facility also has a living room, dining area, and kitchen. The 5 residents in the facility appeared well-groomed and well cared-for. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA Velazquez observed half bed rails on the beds of 4 of the residents which Caregiver Jakosalem verified. Caregiver Jakosalem provided LPA with the resident's files and LPA observed written physician orders for the bed rails but it did not specify the need for the bed rails. Caregiver Jakosalem and AD Anca will obtain updated written physician orders for the residents with bed rails and maintain it in the resident files. Resident bathrooms were checked. Resident bath towels and personal hygiene supplies were adequately stocked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature measured at 117.1 degrees Fahrenheit in the first bathroom, at 115.5 degrees Fahrenheit in the second bathroom and at 115.3 degrees in the third bathroom which Caregiver Jakosalem verified.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: DIAMOND SENIOR CARE 2
FACILITY NUMBER: 306005258
VISIT DATE: 03/25/2022
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LPA Velazquez inspected the kitchen along with Caregiver Jakosalem. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged. The smoke and carbon monoxide detectors are hardwired were tested and found to be operational. Medications, toxins and sharps were locked and inaccessible to residents. The auditory alarms throughout the facility were in operating condition but 2 of them emitted a weaker signal and LPA Velazquez advised Caregiver Jakosalem to replace those batteries. First Aid kit was checked and found to be in order. The facility did have a First Aid guide and LPA Velazquez advised AD Anca to obtain an updated First Aid manual.

LPA Velazquez along with Caregiver Jakosalem and AD Anca toured the outside grounds. LPA, Caregiver, and AD observed a pool in the backyard that is enclosed by a locked gate. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and the exit gates were operational. There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit. LPA Velazquez informed AD Anca to ensure a written physician's order indicating the need for the bed rails is present in a resident's file pursuant to Title 22 Regulation Section 87608 Postural Supports. LPA also reviewed and provided a copy of Title 22 Regulation Section 87608 Postural Supports. Administrator Anca acknowledged receiving a copy of said regulation.



There were no deficiencies issued during this Required 1 Year inspection. An exit interview was conducted with Administrator Ana Anca and a copy of this report was provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC809 (FAS) - (06/04)
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