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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701086
Report Date: 11/14/2024
Date Signed: 11/14/2024 01:16:00 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/08/2024 and conducted by Evaluator Victoria Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241108145835
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:
11/14/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Mohamed MassaquoiTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not ensure that the resident was appropriately dressed.
Staff did not ensure that the resident attended scheduled appointment on time.
Staff did not ensure that the resident was picked up in a timely manner from scheduled appointment.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 11/14/24 at 8:30am and met with Mohamed Massaquoi and stated the purpose of the visit. LPA conducted interviews of resident #1 (R1) and Home Health and Staff #1 (S1-S3) during this visit. LPA obtained a copy of text messages, discharge documents, and email and Home Health notes during this visit.

Regarding allegation, "Staff did not ensure that the resident was appropriately dressed", LPA obtained information through interviews of R1, S1-S3, Home Health, and Administrator that R1 went to 2 doctor appointments with compression socks and no shoes. All concur that due to swelling, R1 refused to wear shoes in and about the home and again to both appointments. Home Health assisted with trimming the shoes to allow some foot coverage. R1 is pleased with the trimmed shoes, however, Home Health recommended shoes that can be adjusted. LPA observed that the shoes were ordered and are due to arrive today.
Unsubstantiated
Estimated Days of Completion: 30
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20241108145835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/14/2024
NARRATIVE
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Regarding allegation, "Staff did not ensure that the resident attended scheduled appointment on time", LPA obtained information that R1 is taken to appointments by a transportation company. Based on interviews R1 was always picked up at least 30 minutes prior to the scheduled appointment. The facility was unaware that R1 was late to the appointment. R1 has a Power of Attorney (POA) but during Dr Office visits R1 is responsible for self since admittance. The Physician Report dated 5/17/24 indicates R1 is able to leave the facility unassisted and there is no diagnosis of Mild Cognitive Impairment nor Dementia.

Regarding allegation, "Staff did not ensure that the resident was picked up in a timely manner from scheduled appointment, LPA obtained information through interviews that the facility staff was unaware that R1 was picked up late from a doctor appointment by the transportation company. The Administrator indicated that contact with the POA regarding options to ensure R1 is not late for or picked up late from appointments.

Based on a review of discharge documents, text messages, email and consistency of interviews, all three allegations are deemed Unsubstantiated.

The investigation revealed the preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNSUBSTANTIATED. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies 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: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
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