Diamond Terraces

Type of visit: Required - 1 Year

On 4/8/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Administrator (A1) Jan Norman, LPA was granted entry. 22 residents were present during inspection. Administrator (A2) Robert Norman arrived shortly after LPA’s arrival. LPA toured facility with A1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Samples of resident’s medications were checked and observed locked in cabinet. Clients’ MARS was reviewed. Samples of medications reviewed. Fire extinguisher reviewed with a service date of: 10/23/25. Fire drill completed on 2/8/26. Clients' bedrooms were toured and reviewed. Cleaning chemicals were observed stored and locked in closet. Residents bedrooms observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a range of 105 to 114.8 degrees F in 3 bathrooms. Outside of facility toured. Outside observed free of debris. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Freezer temperature observed at 4 degrees F and refrigerator temperature maintained at 40 degrees F. Smoke detectors and carbon monoxide were tested and observed to be operational. All clients’ files reviewed to have all the required documents. Staff’s files reviewed and 1 required document was missing. Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. Exit Interview conducted. LPA is requesting the following documents be submitted to the Fresno CCL office by 4/7/26: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A) A copy of this report was provided to Administrator, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Mar 24, 2026

Type of visit: Required - 1 Year

On 4/8/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Staff (S1) Claudia Walthing, LPA was granted entry. 20 residents were present during inspection. Administrator (A1) Jan Norman arrived shortly after LPA’s arrival. LPA toured facility with A1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Samples of resident’s medications were checked and observed locked in cabinet. Clients’ MARS was reviewed. Samples of medications reviewed. Fire extinguisher reviewed with a service date of: 10/16/24. Fire drill completed on 1/8/25. Clients' bedrooms were toured and reviewed. Cleaning chemicals were observed stored and locked in closet. Residents bedrooms observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a range of 110.8 to 117.6 degrees F in 3 bathrooms. Outside of facility toured. Outside observed free of debris. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Freezer temperature observed at 2 degrees F and refrigerator temperature maintained at 40 degrees F. Smoke detectors and carbon monoxide were tested and observed to be operational. All clients’ files and staff’s files reviewed to have all the required documents. No deficiencies issued during this inspection. Exit Interview conducted. LPA is requesting the following documents be submitted to the Fresno CCL office by 4/22/25: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A) A copy of this report was provided to A1, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Apr 8, 2025

Allegation investigated: Staff left resident in dirty clothes Due to staff neglect, resident received injuries Staff did not allow resident to sleep in resident's own bed

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to open a complaint on the allegations listed above. LPA met with Facility staff and explained the purpose of today's visit. Staff left resident in dirty clothes. Regarding the allegation Staff left resident in dirty clothes. LPA Hurt observed several facility residents in the common area of the facility. The residents all appeared to be wearing clean clothes, including clean matching socks. LPA Hurt observed several resident bedrooms with clean clothes in closets and dressers. LPA Hurt observed facility staff doing resident laundry. LPA Hurt interviewed several facility staff who all stated the resident laundry is done and the residents clothes are changed daily. Based on observation, and interviews conducted during this investigation by Department of Social Services staff this allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Unsubstantiated Regarding the allegation Due to staff neglect, resident received injuries. Resident 1's responsible party, the reporting party, and the facility staff was not able to provide any photos, incident reports, or medical documentation injuries possibly caused by neglect. Based on interviews conducted during this investigation by Department of Social Services staff this allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation Staff did not allow resident to sleep in resident's own bed. Facility staff interviewed all stated there was never an incident where they did not allow Resident 1 to sleep in their own bed. Facility staff, and Resident 1's responsible party both stated they remember Resident 1 would at times come out of her room at night and sleep on the couch, and also in other residents bedrooms. Facility staff stated they would supervise Resident 1, and attempt to re direct back to their own bedroom. Based on interviews conducted during this investigation by Department of Social Services staff this allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with facility staff, and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 27, 2024 · control 24-AS-20240422124007

Allegation investigated: Staff neglect resulted in resident sustaining a fall injury Facility did not report injury to resident’s authorized representative

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on the allegations listed above. LPA met with Facility Licensee Jan Norman, and explained the purpose of today's visit. Regarding the allegation Staff neglect resulted in resident sustaining a fall injury. Resident 1 needs assistance with transfer to and from their wheelchair. Facility staff has been advised to have hands on Resident 1 at all times during any transfers. Staff 1 stated Resident 1 did sustain two separate falls at the facility on March 10, 2024, and April 25, 2024. Staff 1 stated both falls occured when facility staff removed their hands from Resident 1 for a brief moment during transfer from wheelchair. Resident 1's fall on April 25, 2024 resulted in substantial bruising to the face, and head area. Based on LPA's interview conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Continued... Substantiated ...Continued Regarding the allegation Facility did not report injury to resident’s authorized representative. Staff 1 stated they did not report Resident 1's fall to State Licensing, or their Responsible Party. Based on LPA interview conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The following deficiencies are being cited Per Title 22 Regulations. Exit interview conducted with facility Licensee Jan Norman and a copy of this report along with appeals rights provided.the state’s words, verbatim · CDSS document, May 8, 2024 · control 24-AS-20240429084845

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 9, 2024

87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. The following requirement has ot been met as evidenced by: Resident 1 sustained two separate falls in the facility due to staff not properly transferring, which poses an immediate, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Licensee will conduct "transfer" training with facility care staff, and send proof to LPA by POC date of 05/09/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: May 22, 2024

87211 Reporting Requirement (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: The following requirement has not been met as evidenced by: State Licensing, and Resident 1's Responsible Party was not notified of Resident 1's fall resulting in injury, facility did not follow instructions on licensing form LIC624, which poses a potential, health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Licensee will conduct training with facility staff on Reporting Requirements, which poses a potential, health, safety, risk to residents in care.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Facility Staff, Nicholas Alvidrez, Continual Administrator's Certification Licensee Robert Norman expires 06/17/2025. There are currently 23 residents who reside at this home and there is 7 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The facility does not have documented disaster drills as required. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. Water temperature measures 116 degrees. LPA Hurt observed cleaning supplies in the kitchen near food items. Resident 1 does not have updated yearly Physician's Report as required. Resident 2 does not have required "Oxygen in Use" sign on door. Resident 3 does not have completed Admission Agreement in file. Staff does not have required / updated dementia training. Resident 4's medications are pre poured, and not in original containers. The facility entrance smells of urine, and several areas in the facility need dusting and deep cleaning. The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing. Exit interview conducted with Facility Staff, Nicholas Alvidrez, and copy of report left at facilitythe state’s words, verbatim · CDSS document, Mar 9, 2024