Diamond Bar RCFE

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Deficiencies in conjunction with a pre licensing visit (pending license #198603903). The purpose is to issue deficiency that was observed by LPA. During the visit on 06/29/2026, applicant and administrator confirmed that they have (20 bedridden residents in house and but fire clearance is approved for (6) non ambulatory residents, where (1) can be bedridden in Room #6. However, LPA observed (1) bedridden female resident in Room #4. This additional bedridden resident is not approved or cleared by the fire department/fire marshall. Deficiency is noted on LIC 809D. Exit interview, a copy of this report and Appeals Rights were provided to Lilyvi Santos, Care Staff and Shelly Yamashiro, Administrator.the state’s words, verbatim · CDSS document, Jun 29, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Jun 30, 2026

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (2) Bedridden persons. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in that the facility is retaining (2) bedridden residents (R1 & R2), one of which (R1) is presently located in room #4 which is not designated by the Fire department as a bedridden room. Facility does not have bedridden fire clearance for Room #4. This poses an immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 29, 2026

Plan of correction: Care staff and administrator agreed to transfer or relocate one of the bedridden residents/R1. Administrator to submit proof that R1was relocated to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Elena Mallett conducted an unannounced annual inspection of the facility. LPA arrived and met with staff in charge, Gloria. The purpose of today’s visit was explained. Administrator Shelly Yamishiro joined the visit shortly after and stayed for twenty minutes and then had to leave on personal business.Administrator returned for twenty minutes later in the visit and then left again. Staff in charge, Gloria assisted with the remainder of the visit. The facility is licensed to serve 6 elderly , non-ambulatory residents, one of which may be bedridden, ages 60 and above. There is hospice waiver for 4. Bedrooms 1,2,3,4 and 5 are approved for non-ambulatory and bedroom 6 is approved for bedridden. There are currently no bedridden residents. Two residents are currently on hospice. The facility is a single-story home located in a residential area in Diamond Bar, Ca. A tour of the facility includes: living room, family room, kitchen, dining area, staff room, 6 bedrooms, 3 bathrooms (1 bathroom located in resident room), front yard, back yard with swimming pool and attached garage with laundry. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today’s visit and the initial visit and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility and a designated Infection Control Lead. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Dementia Plan and training, and facility maintains the required current liability insurance. Physical Plant & Environment Safety: LPA toured facility. The facility is well maintained and walkways and hallways are free of debris and obstruction. Residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The required furnishings, light and bed linens were observed. There were extra linens and towels present. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. There is an inaccessible swimming pool at the facility. It has a taller than 5 ft fence and is locked. A shaded table and chairs were present to allow the residents to enjoy the outdoors. There are no security bars or weapons on the premises. The hot water temperature was measured within Title 22 requirements ( 105 F to 120 F) in resident bathrooms . All storage areas for cleaning solutions, toxins, knives, sharps and hazardous items are kept locked and are inaccessible to residents. Smoke detectors are present in each resident room and the living room. All were observed to be operable. A carbon monoxide detector was present and operable. There were 2 fire extinguishers present that was observed to be fully charged. Staffing: There appears to be sufficient staffing at all times in the facility. The night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training: Staff files are kept in a secure location. LPA reviewed 5 staff files. Files were reviewed for Criminal Record Clearance, Health Screening, Current First Aid and CPR as well as initial and ongoing training for care of the Elderly. No deficiencies were observed. Administrator’s certificate is current until 10/05/27. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Medical Consent, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 5 Resident Files and a deficiency was observed. See 809-D. Administrator advised to document when resident refuses inventory of personal items. Residents Rights-Information: Residents are provided with telephone and internet at the facility. All the required postings were observed. Planned Activities: Facility offers activities like singing for residents, coloring/drawing, chair exercises, a central TV viewing area for residents to enjoy together. Residents are taken outside for walks. There is an outdoor furnished patio area available for the residents. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Food was stored separately from cleaners, toxins and poisons. Appliances were observed to be operable and able to properly store and prepare food. Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a locked closet and are in their original containers. LPA reviewed 4 residents’ medications and there was a defieciency cited. Please see 809-D. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Emergency food, water and portable oxygen were observed. A full First Aid kit and Manual were available. Last Disaster drill was documented on 04//02/25. Administrator to send documentation of disaster drills to LPA. Residents with Special Health Needs: 3 resident rooms were observed to have beds with bedrails. A defieciency was cited. See 809-D . Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies. Facility admits residents with dementia and staff have all required training documented within personnel files. There are currently no bedridden residents. Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit are documented on the 809(D). Exit interview was held with staff in charge Gloria and a copy of this Licensing report was provided along with Appeal Rights.the state’s words, verbatim · CDSS document, Feb 9, 2026

Allegation investigated: Staff did not seek proper medical attention for resident. Staff are not allowing resident to use the phone.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the above allegations. LPA met with Gloria Estrobo, Caregiver and explained the purpose of the visit. At 12:43pm, Administrator Shelly Yamashiro arrived and assisted LPA with the investigation. The investigation consisted of the following: LPA obtained copies of the staff & resident rosters, and Resident #1 (R1)'s pertinent files such as: Identification/Emergency Information, Admission Agreement, Physician's report, Need/Services Plan, Discharge Summary notes, Sign in and out sheet (October 2025), Medication Administration Record (MAR) (October 2025) and Kaiser Permanente Discharge summary. LPA interviewed Staff #1 (S1) - Staff #3 (S3) and Resident #1 (R1) - Resident #2 (R2). LPA attempted to interview Resident #3 (R3) - Resident #6 (R6) but was unsuccessful due to their cognitive capacities. *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: Allegation: "Staff did not seek proper medical attention for resident." It is alleged that R1 was complaining about being in pain due to swollen legs and a nurse visited but was unable to give R1 medication. (3) of (3) staff interviewed stated that R1 was admitted with lower extremity swelling on October 07, 2025. Staff stated that R1 has follow-up care from a Kaiser nurse twice a week and is now receiving care from a home health nurse two times a week, with the latest visit on 10/24/2025. Staff also stated that R1 was complaining about leg pain when R1 first arrived, and staff have assisted R1 by elevating their foot and informing the Administrator. Staff interviewed stated that when any resident is in pain, including R1, they attend to them right away, assess, document and report to the Administrator. R1-R2 stated that staff are kind, that they help them when they are in pain and assist with their medical needs. Documentation reviewed and interviews conducted do not corroborate this allegation. Allegation: "Staff are not allowing resident to use the phone." It is alleged that the staff won’t allow resident to use the phone. (3) of (3) staff interviewed denied the allegation. S1 stated that they allow R1 to use their personal cell phone to call family members or friends. In addition, the facility has a working land line that residents can use if they want to. Interviewed residents cannot corroborate the allegation. R1 stated that they do not have their own cell phone, however the staff allow them to use the staff's personal phone to call family members or friends. Therefore there was insufficient evidence to corroborate with this allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held and a copy of this report was provided to the Administrator, Shelly Yamashiro.the state’s words, verbatim · CDSS document, Oct 27, 2025 · control 28-AS-20251023152139

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the annual inspection. LPA met with Staff, Taren Mente. The initial visit was held on 2/20/25. During the visit today, LPA inspected the remaining domains of the CARE tools. Staffing: There is sufficient staffing at the facility and backup staff if needed. Staff employed have fingerprint clearance and associated to the facility. Personnel Records-Training: LPA reviewed 3 staff files and all documents are in file. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Resident Records-Incident Reports: LPA reviewed 3 resident files and the following documents are found - admission agreements, Identification & Emergency Information, Physician's Report, Consent forms, Resident rights, Safeguards for Personal Property/Valuables form. Resident Rights-Information: The Complaint poster, Local Ombudsman, and Residents personal rights are posted. Incidental Medical & Dental: The medications are centrally stored and locked in the cabinet. Resident medications were reviewed and marked in the Medication Administration Record (MAR) log when given. Resident with Special Needs: There are currently no residents with a prohibited or restricted health condition or using oxygen. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. LPA provided a technical advisory for disaster drills. No deficiencies were issued today. An exit interview was held and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Feb 27, 2025

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection. LPA met with Staff, Taren Mente, and explained the purpose of the visit. The fire clearance has been approved for a capacity of 6 residents, which 5 may be non-ambulatory and 1 bedridden. Bedroom #6 is approved for bedridden. The hospice waiver is approved for 4 residents. LPA inspected the facility using the Compliance and Regulatory Enforcement (CARE) tools. Infection Control: Facility is continuing to follow their Infection Control plan. Staff are wearing gloves to assist residents. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 4 residents residing at the facility. Structure/Physical Plant: The facility is a single story home with 6 private resident bedrooms, 1 staff room, 4 bathrooms (2 communal bathroom, 1 in bedroom #4, and 1 jack and jill bathroom), living room, dining room, kitchen, and attached garage. The facility has a swimming pool in the backyard and is surrounded by a locked gate. Bathrooms have non-skid mats in the shower area and grab bars. Knives, cleaning solutions, and disinfectants are locked. The hot water temperature was measured between the required range of 105-120 degrees F. The backyard has a table and chairs for residents to use. The facility has auditory devices at the exit doors and the resident room's sliding doors. Food Service: Sufficient food supplies of 2 day perishable and at least a week of non-perishable are observed. The kitchen is kept clean and sanitary. The refrigerator is maintained at 40 degrees F or below and the freezer at 0 degrees F or below. Planned Activities: The facility has sufficient space to accommodate indoor and outdoor activities. No deficiencies were observed today. LPA will return another day to complete the remainder of the domains. A copy of this report was given to Staff Taren.the state’s words, verbatim · CDSS document, Feb 20, 2025

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced visit for the purpose of a post-licensing inspection. LPA met with Administrator, Andrew Mente, and explained the purpose of the visit. The fire clearance has been approved for a capacity of 6 residents, which 5 may be non-ambulatory and 1 bedridden. Bedroom #6 is approved for bedridden. The hospice waiver is approved for 4 residents. The facility is a single story home with 6 private resident bedrooms, 1 staff room, 4 bathrooms (2 communal bathroom, 1 in bedroom #4, and 1 jack and jill bathroom), living room, dining room, kitchen, and attached garage. The facility has a swimming pool in the backyard and is surrounded by a locked gate. The bathrooms have non-skid mats in the shower area and grab bars. The backyard has a shaded area with table and chairs. Facility has an operable smoke detector in each room and a carbon monoxide detector located near resident rooms. Knives, cleaning solutions, and disinfectants are locked, making them inaccessible to residents. The facility has auditory devices located by the exit doors and in each of the resident room's sliding doors. There is a sufficient food supply of 2 day perishable and at least a week of non-perishable food maintained at the facility. Staff and Residents files are stored and maintained at the facility. LPA reviewed resident and staff files to ensure all required forms are in their files. Medications are centrally stored and locked inside a kitchen cupboard. LPA reviewed medications and there are no discrepancies. The facility accepts and retains residents with dementia and/or hospice. The facility has a "no smoking oxygen in use" sign posted at the facility and in front of the resident's room. Emergency Disaster Plan is easily accessible and disaster drills are conducted quarterly. No deficiencies are issued today. An exit interview was held and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, May 10, 2024

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Cynthia Chan and Christian Gutierrez conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. LPA met with the applicant, Andrew Mente and Administrator, Les Dee. An application was submitted to CCLD for a Change of Ownership of a Residential Care Facility for the Elderly, ages 60 years and older. The fire clearance has been approved for a capacity of 6 residents, which 5 may be non-ambulatory and 1 bedridden. Bedroom #6 is approved for bedridden. The hospice waiver is approved for 4 residents. Infection Control: The licensee has developed an Infection Control Plan and designated a lead staff to conduct training. Facility has sufficient PPE supplies and will provide on-going training to staff on infection control. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 6 residents residing at the facility. Structure/Physical Plant: The facility is a single story home with 6 private resident bedrooms, 1 staff room, 4 bathrooms (2 communal bathroom, 1 in bedroom #4, and 1 jack and jill bathroom), living room, dining room, kitchen, and attached garage. The facility has a swimming pool in the backyard and is surrounded by a locked gate. The bathrooms have non-skid mats in the shower area and grab bars. Facility has an operable smoke detector in each room and a carbon monoxide detector located near resident rooms. Knives, cleaning solutions, and disinfectants are locked, making them inaccessible to residents. There are no firearms or weapons stored at the facility. The hot water temperature was measured between the required range of 105-120 degrees F. The backyard has a table and chairs for residents to use. The facility has auditory devices located by the exit doors and in each of the resident room's sliding doors. Food Service: There is a sufficient food supply of 2 day perishable and at least a week of non-perishable food maintained at the facility. The kitchen is kept clean and sanitary. All the appliances were in working order. Sufficient amount of tableware, dishes, and utensils are observed. The refrigerator is maintained at 40 degrees F or below and the freezer at 0 degrees F or below. The knives and sharps are stored and locked in a cabinet. Staff and Residents files: Staff and Residents files are stored and maintained at the facility. LPA reviewed resident and staff files to ensure all required forms are in their files. Resident Rights/Information: Resident rights, Resident councils, and complaint posters are posted in a prominent area. Planned Activities: The facility has sufficient space to accommodate indoor and outdoor activities. Incidental Medical and Dental: Medications are centrally stored and locked inside a kitchen cupboard. The first aid kit contains all the required supplies along with the current first aid manual. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. There is a backup generator available at the facility. Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. The facility has "no smoking-oxygen in use" signs posted at the facility and in front of the resident's room. LPA conducted the Component III with the applicant and administrator. The Pre-licensing is complete and the facility has no deficiencies. An exit interview was held and a copy of this report was given to the applicant.the state’s words, verbatim · CDSS document, Feb 13, 2024

Type of visit: Office

Component II completion: Successful Facility Type: Residential Care Facility for Elderly (RCFE) Application Type: Change in Ownership Capacity: 6 Census (if any clients in care): 6 COMP II Participants: Leslie Dee, Administrator Andrew Mente, Applicant Interview Method: Telephone interview On January 29, 2024 at 1:00 PM, Applicant and Administrator participated in COMP II. Identification of the Applicant and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant and Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. During COMP II, CAB analyst confirmed Applicant and Administrator’s understanding of following areas: 1. Facility Operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing Requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readiness Exit interview conducted with Applicant and Administrator. Copy of report sent via email and informed to return sign copy by end of business day to CAB.the state’s words, verbatim · CDSS document, Jan 29, 2024