<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701123
Report Date: 09/01/2023
Date Signed: 09/01/2023 05:07:25 PM

Document Has Been Signed on 09/01/2023 05:07 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 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: 5DATE:
09/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Chi OnwuliTIME COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 9/1//23 at approximately 2:15PM Licensing Program Analysts (LPAs) Jennifer Fain and Maja Jensen arrived at the facility unannounced to conduct a case management. LPAs met with co-administrator’s and explained the reason for the visit. The facility is licensed for 6 residents and currently has 5 residents in care.
LPAs provided Technical Assistance on restricted health conditions including but not limited to catheter care and diabetes, reporting requirements, evictions and resident files.

LPAs interviewed the co-administrator and based on interview, resident 1 (R1) was sent to the emergency department on multiple occasions during August of 2023, however no incident reports were received by the department.

LPAs also observed the facility to have a resident with an indwelling catheter which is a restricted health condition, however there was no restricted health condition care plan on file.

Pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code deficiencies were cited.

An exit interview was conducted and a copy of this report was provided to Licensee.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/01/2023 05:07 PM - It Cannot Be Edited


Created By: Jennifer Fain On 09/01/2023 at 04:20 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 SENIOR CARE
FACILITY NUMBER: 342701123

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2023
Section Cited
CCR
87612(a)(2)

1
2
3
4
5
6
7
Restricted Health Conditions
The licensee may provide care for residents who have any of the following restricted health conditions...
Catheter care as specified in Section 87623.


1
2
3
4
5
6
7
Licensee states that she will send a plan for catheter resident care by POC date. Plan will be sent to jennifer.fain@dss.ca.gov by end of day 9/2/23.
8
9
10
11
12
13
14
Based on observation and interview, the resident file for R1 does not address the care plan for indwelling catheter care. This poses an immediate risk to the health, safety and personal rights of residents in care.
8
9
10
11
12
13
14
Type B
09/29/2023
Section Cited
CCR87211(a)(1)(D)

1
2
3
4
5
6
7
Reporting Requirements
Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement has not been met as evidenced by:
1
2
3
4
5
6
7
Licensee states that training for staff will occur within 30 days and proof of training will be sent to LPA Fain at jennifer.fain.dss.ca.gov by POC date.
8
9
10
11
12
13
14
Based on record review LPA verified incident reports were not sent to the department for R1's ED visits.
8
9
10
11
12
13
14
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: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2