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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002906
Report Date: 06/18/2024
Date Signed: 06/18/2024 03:37:02 PM

Document Has Been Signed on 06/18/2024 03:37 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:DIAMOND CREEK SENIOR CARE LLCFACILITY NUMBER:
315002906
ADMINISTRATOR/
DIRECTOR:
SVISTUN, MIHAELAFACILITY TYPE:
740
ADDRESS:2597 WATERFORD GLEN CIRCLETELEPHONE:
(916) 410-8130
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 6DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Kay Williams, Lead CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA spoke with Administrator Mihaela Svistun over the phone and met with Caregiver Kay Williams during today's inspection.

LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 6 resident rooms, 1 staff room, 3 bathrooms, kitchen, common living spaces, backyard and the garage area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the backyard and all exits are accessible and unlocked. There is a pool present in the backyard with a locked gate surrounding the pool. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete.

LPA reviewed 3 of 6 resident files and 2 staff files. LPA reviewed medications of two residents comparing with Centrally Stored Medication Record and physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates and training completed. LPA observed a copy of current liability insurance.

LPA observed resident has several expired medications in their medication container. Deficiencies cited on 809-D. Exit interview conducted and appeal rights provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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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Document Has Been Signed on 06/18/2024 03:37 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 06/18/2024 at 03:27 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
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: DIAMOND CREEK SENIOR CARE LLC

FACILITY NUMBER: 315002906

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(4)
87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4)The licensee shall assist residents with self-administered medications as needed.
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 cited above in 1 out of 3 resident medications which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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Administrator to dispose of all expired medications for R1. Administrator agrees to conduct a medication review for all residents in care and dispose of all medications that are expired and obtain a new medication. Administrator to complete review by 7/01/25, and send LPA CSMR indicating all medications destroyed.
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.
SUPERVISOR'S NAME:Troy Ordonez
LICENSING EVALUATOR NAME:Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
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