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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701301
Report Date: 07/05/2023
Date Signed: 07/11/2023 03:54:46 PM

Document Has Been Signed on 07/11/2023 03:54 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DIAMOND CARE HOME FOR SENIORS IIFACILITY NUMBER:
392701301
ADMINISTRATOR:VILLAMIL, EMMAFACILITY TYPE:
740
ADDRESS:738 CHESHIRE CT.TELEPHONE:
(209) 482-8943
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 6CENSUS: 0DATE:
07/05/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Emma VillamilTIME COMPLETED:
01:00 PM
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Announced Prelicensing visit made out to this facility on 07/05/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the Applicant Emma Villamil. Brief interview was conducted with the facility Applicant at this time.
This Applicant was seeking licensure for a 6-bed RCFE non ambulatory with an approved dementia program and hospice waiver for (6) residents at any given time. A bedridden fire clearance was also granted for (2) residents at any given time with designated bedrooms.
Tour of this facility was conducted.
Kitchen area was toured. Cabinets and drawers were reviewed. Knives were properly stored and locked in a cabinet made inaccessible to the residents at this time.
Food supply was reviewed for the adequate 2-day perishable and 7-day nonperishable quantities at this time.
Fire extinguisher, located in the kitchen area, was observed to have been purchased from a department store with the receipt attached. It was observed that it was purchased on 04/03/2023 and in compliance at this time.
Living room, dining area, and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
Resident bedrooms were toured. Bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Resident restrooms were toured. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
Grab bars and non skid mats were observed to be present and able to meet the needs of the residents at this time.
Garage area was toured. It was observed that the laundry machines, washer and dryer, were present. All cleaning agents were observed to be locked and made inaccessible to the residents at this time.
A review of the medication closet, located upon entrance to this facility, was observed to be locked and made inaccessible at this time.
A tour of the exterior grounds was conducted.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2023
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: DIAMOND CARE HOME FOR SENIORS II
FACILITY NUMBER: 392701301
VISIT DATE: 07/05/2023
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A review of the facility perimeter fence, side gates, and all other exits were conducted.
First aid kit was observed to be present and contained all of the required components at this time.
The following forms and documents were requested to be updated and submitted into CCL at this time:

LIC 308

LIC 400

LIC 500

LIC 610

This facility was found to be in compliance at this time.

The Component III was waived at this time since this Applicant has been a Licensee prior to this location change request.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
LIC809 (FAS) - (06/04)
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