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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701086
Report Date: 07/27/2022
Date Signed: 07/27/2022 11:30:26 AM

Document Has Been Signed on 07/27/2022 11:30 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DIAMOND OAK GUEST HOMEFACILITY NUMBER:
342701086
ADMINISTRATOR:MASSAQUOI, MOHAMEDFACILITY TYPE:
740
ADDRESS:8632 DIAMOND OAK WAYTELEPHONE:
(916) 685-4099
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
07/27/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Niomi Massaquoi TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 7/27/22 at 10:00AM to conduct a Pre-licensing inspection visit. LPA met with Niomi Massaquoi and explained the purpose of the visit. Administrator certificate expires 7/17/23 for Mohamed Massaquoi.

The facility is licensed for a capacity of 6 residents. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents.

LPA observed 2-day perishables and a supply of 7-day non-perishables during this visit. LPA observed exit alarms during this visit. Staff demonstrated the use of Medication Administration Record (MAR).

The temperature inside the facility was observed to be at 69*F which is within the required range of 68-85*F. The hot water temperature was measured at 108.7*F which is within the required range of 105-120*F.

LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Component III conducted-Licensure pending.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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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