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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701086
Report Date: 07/02/2024
Date Signed: 07/02/2024 05:18:45 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/02/2024 05:18 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/
DIRECTOR:		MASSAQUOI, MOHAMEDFACILITY TYPE:
740
ADDRESS:8632 DIAMOND OAK WAYTELEPHONE:
(916) 685-4099
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
07/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Mohamed MassaquoiTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 7/2/24 at 2:30pm. LPA met with Niomi Massaquoi, Mohamed Massaquoi, Angelene Harris and stated the purpose of todays visit. LPA observed the Administrator Certificate for Mohamed Massaquoi expired on 7/17/23. LPA observed Administrator submitted renewal documents to Community Care Licensing (CCL). The most current emergency drill was conducted on 4/20/24.

The facility is licensed for a capacity of 6 residents of which 5 may be non-ambulatory and 2 may receive hospice care services. There is 0 residents receiving hospice care services during this visit. Non-ambulatory residents may reside in rooms 1,2,5,6,7 not in room 4. 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 7-day non-perishables.

The temperature inside the facility was observed to be at 68*F which is within the required range of 68-85*F. The hot water temperature was measured at 116.6*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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 342701086
VISIT DATE: 07/02/2024
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Upon a file review the following items were discussed to be submitted with any changes annually:
Licensing fees-Current
Criminal Record Clearances LIS536-Current
Administrative Organization LIC309-Current
Designation of Administrative Responsibility LIC308-Submit
Personnel Report LIC500-Submit
Affidavit Regarding Client/Resident Cash Resources LIC400-NA
Surety Bond LIC402-NA
Emergency Disaster Plan LIC610E-Submit
Facility Floor Plan/Plot Plan LIC999-Current
Fire Clearance (consistent with terms and limitations of license)-NA
Qualifications of Administrator/Facility Manager-Submit
Articles of Incorporation/Organization, Constitution and bylaws-NA
Partnership Agreement-NA
Control of Property-Submit
Plan of Operation (Restricted Health Care Plan)-NA
Admission Policies and Procedures-NA
Health Screening Report-Facility Personnel LIC503-NA
Bacteriological Analysis of Private Water Supply-NA
In-service Training Program-NA
Medication Procedures-NA
Transportation Procedures-NA
Job Description/Personnel Policies-NA
Exemptions/Waivers and Exceptions-Current
First aid/CPR certificates-Current
Liability Insurance-Submit
Infection Control Plan-Submit

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC809 (FAS) - (06/04)
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