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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701123
Report Date: 01/07/2022
Date Signed: 01/07/2022 11:00:19 AM

Document Has Been Signed on 01/07/2022 11:00 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 SENIOR CAREFACILITY NUMBER:
342701123
ADMINISTRATOR:ONWULI, OKAY J.FACILITY TYPE:
740
ADDRESS:8636 DIAMOND OAK WAYTELEPHONE:
(916) 690-8874
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 4DATE:
01/07/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Okay Onwuli TIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Avelina Martinez and Maja Jensen made an unannounced visit to this facility to conduct an pre-licensing inspection on 01/07/2022 at 9:00 AM. LPA met with Okay Onwuli and stated the purpose of today’s visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate, and there are 4 residents residing at this facility. LPA Martinez and LPA Jensen toured the facility with Okay Onwuli on 01/07/2022 at 9:30 am.


LPA Martinez is requesting the following:

Sample of Employee and Resident binders


Covid-19 Mitigation Binder/(LIC 808)
Sample of Oxygen Waiver Documentation
Sample of Hospice-Binder/Hospice Notification form
Sample of Admission Agreement
Exterior Requests
Repair Missing Fence Board
Repair Hallway closet door and framing.
Remove Cob webs from laundry room.
Remove Debris from Backyard

As a result of this pre-licensing inspection, the applicant has not passed the pre-licensing component of the application process. LPA Martinez will return at a later date and time to complete the inspection visit. An exit interview was conducted, and a copy of the is report was given to the applicant.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2022
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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