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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701086
Report Date: 12/23/2021
Date Signed: 12/27/2021 09:22:08 AM

Document Has Been Signed on 12/27/2021 09:22 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:DIAMOND OAK GUEST HOMEFACILITY NUMBER:
342701086
ADMINISTRATOR:MASSAQUOI, MOHAMEDFACILITY TYPE:
735
ADDRESS:8632 DIAMOND OAK WAYTELEPHONE:
(916) 685-4099
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: DATE:
12/23/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Mohamed MassaquoiTIME COMPLETED:
11:49 AM
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Facility Type: Adult Residential Facility
Application Type: Change of ownership (from LLC to INC), Change of facility type (from RCFE to ARF)
Capacity: 6
Census (if any clients in care): 6
COMP II Participants: Mohamed Massaquoi
Interview Method: Telephone interview
On December 23, 2021, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.
During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restricted/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Jude De La Concepcion
LICENSING EVALUATOR NAME: Bethany Hunter
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2021
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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