Diamond Oaks Home Care

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Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 9/15/26 to conduct a Annual Inspection. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator arrived to assist. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home is very clean and residents stated they are happy with care. LPA reviewed 2 resident files. Files are complete and well organized. LPA and Admin discussed documentation needed for hospice residents. (reference PIN 22-24) LPA reviewed 2 staff files. Files are complete and well organized. LPA advised recording actual date that training occurred. No deficiencies are being cited as a result of todays inspection. Report of the visit not recorded the day of visit due to computer malfunction. Exit interview conducted with licensee and copy of report emailed for signature.the state’s words, verbatim · CDSS document, Sep 15, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 8/26/25 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator arrived to assist. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home is very clean and residents stated they are happy with care. LPa and Admin discussed fire extinguisher certification. LPA reviewed 2 resident files. Files are complete and well organized. LPA reviewed 2 staff files. Files are complete and well organized. No deficiencies are being cited as a result of todays inspection. Exit interview conducted with licensee and copy of report left at the facility.the state’s words, verbatim · CDSS document, Aug 26, 2025

Type of visit: Case Management - Other

On 12/18/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Administrator, Richard Garcia . On 11/20/24, licensee submitted a incident report regarding R1. R1 had developed diarrhea while on hospice. Staff coordinated with hospice to manage symptoms. On 11/18/ 24 R1 was sent to the hospital due to decline. In the hospital, R1 did not respond to medical treatments and died on 11/30/24. LPA's records review and interview found that staff coordinated with hospice services and sought appropriate medical attention timely. As a result of today’s inspection, no deficiencies were noted. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Dec 18, 2024

Allegation investigated: Staff did not provide adequate supervision resulting in residents eloping from facility. Resident personal rights violated.

On 10/24/24, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Administator, Richard Garcia, to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. Records review found that R1 has a dementia diagnosis with “sundowning” wandering behaviors. Interviews with neighbors found reports of several instances in the late afternoon where neighbors observed R1 alone walking in the cul-de-sac unaccompanied by staff. On 9/23/24, R1 was found by a neighbor to be sitting outside on neighbor’s porch furniture. Neighbor reported that when staff arrived, staff approached R1 speaking harshly to R1 stating, “What are you doing here? You need to get up or they are going to call the cops!” S1 grabbed one of R1’s arms and tugged on R1 to get up. S1 was being rough which was concerning to RP. S1 stated that R1 has Alzheimer’s. Another staff (S2) arrived next and appeared very agitated. S2 also spoke harshly to R1 and both staff began tugging on R1 very roughly. - report continued- Substantiated Licensee also submitted an incident report for 10/2/24 for R1 leaving unattended and returned to the facility by a neighbor. On 10/2/24, staff did not adhere to 1:1 supervision put in place for R1. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Administrator . Copy of this report and appeal rights provided by email.the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 59-AS-20240924091838

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 25, 2024

Additional Personal Rights of Residents in Privately Operated Facilities (a) (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met based on Records and statements that found R1 left without supervision due to staff not monitoring R1 as instucted by R1's plan. This posed an immediate risk to R1.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: Licensee has updated procedures and monitoring for R1. There have been no further such incidents. This citation is cleared by this visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 25, 2024

Personal Rights of Residents in All Facilities (a)(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met based on statements that S1 and S2 did not treat R1 with respect when redirecting. This posed a potential risk.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: S1 and S2 no longer work at the home. Licensee has retrained staff. No further correction needed at this time. This citation is cleared by visit.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 9/19/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator arrived to assist. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home is very clean and residents stated they are happy with care. LPa and Admin discussed fire extinguisher certification, locking chemicals when staff leave an area. LPA reviewed 4 resident files. Files are complete and well organized. LPA reviewed 2 staff files. Files are complete and well organized. No deficiencies are being cited as a result of todays inspection. Exit interview conducted with licensee and copy of report left at the facility.the state’s words, verbatim · CDSS document, Sep 19, 2024

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 12/12/23 to conduct a Post Licensing Inspection utilizing the CARE inspection tool. LPA met with the caregivers and Administrator, Richard Garcia, and explained the purpose of the visit. . LPA and personnel toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedroom, med cabinet, kitchen and dining. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA reviewed resident files. Files were complete. Staff files were reviewed. Files are complete. No deficiencies are being cited as a result of todays inspection. Exit interview conducted. Report provided copy provided.the state’s words, verbatim · CDSS document, Dec 12, 2023