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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701086
Report Date: 09/12/2023
Date Signed: 09/12/2023 01:18:29 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/12/2023 01:18 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
09/12/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Mohamed MassaquoiTIME COMPLETED:
01:45 PM
NARRATIVE
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On 9/12/23 Licensing Program Analyst (LPA) Jennifer Fain arrived at this facility unannounced to complete an annual inspection visit. LPA met with the administrator, Mohamed Massaquoi, and explained the purpose of the visit.

On arrival staff was preparing to serve lunch. The menu consisted of fish, mashed potatoes with gravy, and mixed steamed vegetables. Some residents ate at the table, some in their rooms. Resident 1 (R 1) had a visit from the Home Health nurse.

LPA completed the file review for residents and staff. LPA observed a signed addendum to the admission agreement notifying residents and their families of the use of cameras in the common areas of the residence.

On 7/23/23 LPA received by email copies of the requested LIC 308, 610E and Liability Insurance.

The facility is not in compliance with Title 22 Regulations, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with Mohamed Massaquoi a copy of the LIC 809 reports, LIC 809-D pages, and Appeals rights were provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023
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 09/12/2023 01:18 PM - It Cannot Be Edited


Created By: Jennifer Fain On 09/12/2023 at 12:52 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DIAMOND OAK GUEST HOME
FACILITY NUMBER: 342701086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2023
Section Cited
CCR
87217

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Safeguards for Resident Cash, Personal Property, and Valuables (b)Every facility shall take…measures to safeguard residents' cash resources, personal property and valuables … The licensee shall give the residents receipts for all such articles … This requirement was not met as evidenced by:
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Administrator states he will complete property safeguards and send copies to LPA at jennifer.fain@dss.ca.gov by POC date.
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Based on file review and interview, 5 of 5 resident files had a blank or incomplete Safeguard for Property or valuables. This
poses a potential Health, Safety, and Personal Rights risk to persons in care.
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Type B
09/29/2023
Section Cited
CCR87463

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Reappraisals (c)The licensee shall arrange a meeting with the resident…, appropriate facility staff, and a representative of the resident’s home health agency, … when there is significant change in the resident’s condition, or once every 12 months… This requirement is not met as evidenced by:
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Administrator states he will get a copy of the current 602 from the physician for (R3) and send a copy to LPA at jennifer.fain@dss.ca.gov
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Based on interview and record review, the licensee did not ensure resident 3's health record was up to date which poses a potential Health, Safety, and 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:Liza King
LICENSING EVALUATOR NAME:Jennifer Fain
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023


LIC809 (FAS) - (06/04)
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