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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881330
Report Date: 08/02/2022
Date Signed: 08/10/2022 02:32:19 PM

Document Has Been Signed on 08/10/2022 02:32 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DIAMOND COTTAGEFACILITY NUMBER:
331881330
ADMINISTRATOR:BRAVO, ARNOLDFACILITY TYPE:
740
ADDRESS:30778 DROPSEED DRIVETELEPHONE:
(951) 926-2398
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 6CENSUS: 5DATE:
08/02/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Arnold Bravo, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Yolanda Delgado conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. At approximately 1:00 PM, LPA met with Administrator Arnold Bravo. An initial application for Change of Ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 3/14/2022 for a total capacity of 6 with five (5) non-ambulatory and one (1) bedridden residents. Fire clearance was granted on 6/24/2022. LPA Delgado observed the following:
Structure:
Facility was a one-story house with four (4) resident bedrooms, two (2) resident bathrooms, living room, dining area and kitchen. There was an attached two car garage in the front of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.
Bedrooms:
Each resident bedroom #2, #3 and #4 will accommodate any non-ambulatory resident, bedroom #1 will accommodate bedridden residents. 4 resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm.
Bathrooms:
The (2) resident bathrooms has a working toilet, wash basin, and shower with an adequate supply of paper towels, toilet paper, and soap. At 1:45 PM, LPA tested the water temperatures in the resident bathrooms. LPA verified water temperature was measured at 106.3 degrees Fahrenheit.
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition.
(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DIAMOND COTTAGE
FACILITY NUMBER: 331881330
VISIT DATE: 08/02/2022
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(CONTINUED FROM LIC 809)
and had sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was located inside the house. Laundry detergents and cleaning supplies were observed in locked laundry room away from residents.
Living/Family room:
There was a living room with furniture for all clients and TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence.
Yards/Outside:
Patio table and chairs were observed in the backyard. There was a gate on the NW side of the property that will need a spring. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the main hallway. Obudsman poster and Let-Us-No poster observed.
General items:
One (1) fire extinguishers were charged and located in the kitchen and one (1) located inside the laundry room. Five (5) smoke alarms and one (1) carbon monoxide detectors were tested and were observed to be in working order. Client records will be stored in a locked cabinet in the hallway. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring. Emergency water supply was insufficient however the required 72-hour emergency food supply was not discernible from the regular food supply. Component III was completed on this day as well.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DIAMOND COTTAGE
FACILITY NUMBER: 331881330
VISIT DATE: 08/02/2022
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(CONTINUED FROM LIC808-C

Pre-Licensing is incomplete and the following corrections to be resolved by 8/9/2022:

obtain additional 72-hour emergency food supply
obtain additional separate emergency water
obtain and post visiting policy
obtain 30-Days of PPE supplies
obtain trash cans with lids for the restroom
obtain stands for paper towels
repair garage light
repair recess light fixtures
remove in-operational cameras
obtain fire place fixture
obtain walkie talkies


An exit interview was conducted, and a copy of this report was given.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC809 (FAS) - (06/04)
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