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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881330
Report Date: 08/21/2024
Date Signed: 08/21/2024 12:22:41 PM

Document Has Been Signed on 08/21/2024 12:22 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DIAMOND COTTAGEFACILITY NUMBER:
331881330
ADMINISTRATOR/
DIRECTOR:		BRAVO, ARNOLDFACILITY TYPE:
740
ADDRESS:30778 DROPSEED DRIVETELEPHONE:
(951) 926-2398
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 6CENSUS: 5DATE:
08/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Staff, Anthony Mike VitoTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Staff, Anthony Mike Vito who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (5) residents present.

The facility is a one story home with (4) bedrooms and (2) bathrooms for the residents. No pools or firearms are being kept at the facility.

Infection Control: The LPA observed hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training.



Physical Plant: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. The carbon monoxide was operational, and the hot water temperature was read at 120F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DIAMOND COTTAGE
FACILITY NUMBER: 331881330
VISIT DATE: 08/21/2024
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Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. The staff schedule was unable to be presented during the time of the visit, the administrator stated they would send it to the LPA by 8/23/2024. The administrator agreed to send copy of liability insurance that had been renewed this past week by Friday 8/23/2024.

Record Review and Resident/Staff Files: LPA reviewed (3) staff files and training. One (1) staff did not have proof of CPR training, and health screening and TB test. Deficency was issued and plan of correction was created. Two (2) resident files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in the facility kitchen. LPA observed the resident medication is being transferred from bubble packs to daily pill boxes. A deficiency was issued and plan of correction was created.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. Through staff interview the facility's last fire drill was conducted May of 2024, documentation of the drill was unable to be shown to the LPA. LPA issued a technical note for the drill to be documented and sent to LPA by Friday 8/23/2024. LPA observed emergency supplies in the and first aid kit.

An exit interview was conducted where this report along with deficiencies and technical notes were reviewed and provided with the staff and Administrator, Venus Bravo over the phone.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
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Document Has Been Signed on 08/21/2024 12:22 PM - It Cannot Be Edited


Created By: Janira Arreola On 08/21/2024 at 12:04 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DIAMOND COTTAGE
FACILITY NUMBER: 331881330

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with (1) staff present during the visit who did not have a complete personnel record. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2024
Plan of Correction
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The administrator agreed to send the LPA the CPR and first aide training, along with health screening and TB test for the staff by the POC due date.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above with daily pill boxes that are being used for resident medications which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2024
Plan of Correction
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The administrator agreed to conducted training with staff and discontinue the use of the pill boxes when administering medications. Documentation of the training is due by the POC due date.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024


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