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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881330
Report Date: 12/06/2024
Date Signed: 12/09/2024 08:37:29 AM

Document Has Been Signed on 12/09/2024 08:37 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
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:
12/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 PM
MET WITH:Mike VitoTIME VISIT/
INSPECTION COMPLETED:
11:45 PM
NARRATIVE
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This Case management– Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Abdoulaye Zerbo on 12-06-24 for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 18-AS-20241127153632. LPA met with Mike Vito and explained purpose of the visit.

During the visit, LPA observed the water temperature to be measuring at 149.5 F. LPA also observed residents with dementia not having a current physician's report.

Based on observations, record review and interview, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809-D.

An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative, Mike Vito.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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 12/09/2024 08:37 AM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 12/04/2024 at 03:45 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: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/02/2025
Section Cited
CCR
87465(h)(5)

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Care of Persons with Dementia: (c) Licensees...shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment...and a reappraisal done at least annually...

This requirement is not met as evidenced by:
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Licensee will ensure all of the residents with dementia shall have an annual medical assessment conducted and will submit proof to LPA by the POC due date
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Based on observation,interview, record reviews, the licensee did not comply with the section cited above in three (3) out of four (5) residents not having a current and updated Physician's Report, which poses a potential health, safety or personal rights risk to persons in care.
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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:Rikesha Stamps
LICENSING EVALUATOR NAME:Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/09/2024 08:37 AM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 12/04/2024 at 03:49 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: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2024
Section Cited
CCR
87303(e)(3)

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(e)Water supplies and plumbing fixtures shall be maintained as follows:
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:
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Licensee to monitor water temperature for 10 days and create a water log that will be sent to LPA Zerbo on 12/12/2024. Staff to check hot water temperature routinely to assure the proper water temperature is maintained at all times.
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Based on observation,interview, record reviews, the licensee did not comply with the section cited above as water temperature was measuring at 149.5 F
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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:Rikesha Stamps
LICENSING EVALUATOR NAME:Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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