Inspection Reports for
Diamond Oaks Residential Care

CA, 95678

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Deficiencies (last 5 years)

Deficiencies (over 5 years) 2 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

50% better than California average
California average: 4 deficiencies/year

Deficiencies per year

8 6 4 2 0
2021
2022
2023
2024
2025

Census

Latest occupancy rate 83% occupied

Based on a October 2025 inspection.

This facility has shown a decline in demand based on occupancy rates.

Occupancy over time

0 3 6 9 12 Aug 2021 Apr 2023 Feb 2024 May 2024 Jan 2025 Oct 2025

Inspection Report

Original Licensing
Census: 5 Capacity: 6 Deficiencies: 0 Date: Oct 7, 2025

Visit Reason
The purpose of the visit was to conduct a pre-licensing inspection for change of ownership.

Findings
There were no deficiencies noted during the inspection.

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystMet with Administrator during the inspection visit.
Jessica RocasAdministratorFacility Administrator met during the inspection.

Inspection Report

Original Licensing
Census: 5 Capacity: 6 Deficiencies: 0 Date: Oct 7, 2025

Visit Reason
The purpose of the visit was to conduct a pre-licensing inspection for change of ownership.

Findings
There were no deficiencies noted during the inspection.

Employees mentioned
NameTitleContext
Jessica RocasAdministratorMet with during inspection
Kevin MknellyLicensing Program AnalystConducted the inspection
Maribeth SentyLicensing Program ManagerNamed in report

Inspection Report

Annual Inspection
Census: 3 Capacity: 6 Deficiencies: 1 Date: Apr 3, 2025

Visit Reason
The inspection was an unannounced annual inspection conducted to ensure compliance with health and safety regulations at the facility.

Findings
The facility was generally clean and residents expressed satisfaction with care. No immediate health, safety, or personal rights violations were observed except for water temperature exceeding the regulatory range in two bathroom locations, which posed a potential risk.

Deficiencies (1)
Water temperature exceeded regulation range, measured above 130 degrees Fahrenheit in two bathroom locations, posing a potential health, safety, or personal rights risk to persons in care.
Report Facts
Capacity: 6 Census: 3 Plan of Correction Due Date: Apr 4, 2025

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the inspection and signed the report
Abigaila BudacAdministratorFacility administrator present during inspection and exit interview

Inspection Report

Annual Inspection
Census: 3 Capacity: 6 Deficiencies: 1 Date: Apr 3, 2025

Visit Reason
Licensing Program Analyst Kevin Mknelly arrived unannounced on April 3, 2025 to conduct an Annual Inspection utilizing the CARE inspection tool. The visit was to ensure health and safety compliance and review facility records.

Findings
The facility was generally clean with no immediate health, safety, or personal rights violations observed except for water temperature exceeding regulation limits in two bathroom locations. A deficiency was cited related to this issue.

Deficiencies (1)
Water temperature in two bathroom locations exceeded 130 degrees Fahrenheit, not complying with regulation requiring taps delivering water at 125 degrees F or above to be identified by warning signs.
Report Facts
Census: 3 Total Capacity: 6 Deficiency count: 1 Plan of Correction Due Date: Apr 4, 2025

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the inspection and cited deficiency
Abigaila BudacAdministrator/DirectorFacility administrator present during inspection

Inspection Report

Census: 3 Capacity: 6 Deficiencies: 0 Date: Jan 28, 2025

Visit Reason
The inspection was a case management visit conducted to perform a health and safety check at the facility.

Findings
The facility was found to be clean and orderly with sufficient staffing to attend to resident care needs. Medications and chemicals were secured, food supplies met requirements, and the home was at a comfortable temperature. No deficiencies were noted during the inspection.

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the case management visit and health and safety check.
Abigaila BudacAdministratorFacility administrator met with the Licensing Program Analyst during the visit.

Inspection Report

Census: 3 Capacity: 6 Deficiencies: 0 Date: Jan 28, 2025

Visit Reason
The inspection was a case management visit conducted to perform a health and safety check at the facility.

Findings
The facility was found to be clean and orderly with sufficient staffing to attend to resident care needs. Medications and chemicals were secured, food supplies met requirements, and the home was at a comfortable temperature. No deficiencies were noted during the inspection.

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the case management visit and inspection.
Abigaila BudacAdministrator/DirectorFacility administrator met during the inspection.

Inspection Report

Complaint Investigation
Census: 3 Capacity: 6 Deficiencies: 2 Date: Oct 1, 2024

Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that staff did not ensure sufficient care and supervision was provided to a resident and did not seek medical treatment in a timely manner.

Complaint Details
The complaint was substantiated regarding insufficient care and supervision and delayed medical treatment for a resident who fell and sustained serious injuries. The allegation regarding food quality was unsubstantiated.
Findings
The investigation substantiated that staff failed to provide necessary physical assistance to a resident who fell and sustained serious injuries, and delayed calling emergency services, resulting in an immediate health and safety risk. Another complaint regarding food quality was found unsubstantiated.

Deficiencies (2)
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met based on records and interviews that found R1 required physical assist while ambulating that was not provided resulting in a fall.
Advanced Directives and Requests Regarding Resuscitative Measures: For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1). This requirement was not met based on records and interviews found R1 had a fall with injury and 9-1-1 services were delayed.
Report Facts
Capacity: 6 Census: 3 Civil penalty: 500 Time lapse: 100

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the complaint investigation and delivered findings
Abigail BudocAdministratorFacility administrator interviewed during investigation
S1CaregiverCaregiver involved in resident fall incident

Inspection Report

Complaint Investigation
Census: 3 Capacity: 6 Deficiencies: 2 Date: Oct 1, 2024

Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2024-08-05 regarding insufficient care and supervision of a resident and delayed medical treatment after a fall incident on 2024-08-04.

Complaint Details
The complaint was substantiated. Staff failed to ensure sufficient care and supervision for resident R1, who fell and sustained serious injuries. Staff delayed seeking timely medical treatment by not calling 9-1-1 immediately, instead contacting Hospice and the Administrator first. The delay was approximately 1 hour and 40 minutes before R1 was admitted to the emergency room. Another complaint about food quality was unsubstantiated.
Findings
The investigation substantiated that staff did not provide sufficient care and supervision to resident R1, who required assistance with ambulation, resulting in a fall and serious injury. Staff delayed calling 9-1-1, instead contacting Hospice and the Administrator, causing a delay of approximately 1 hour and 40 minutes before emergency care was received. Another allegation regarding food quality was found unsubstantiated.

Deficiencies (2)
Failure to regularly observe residents for changes in physical, mental, emotional and social functioning and provide appropriate assistance, resulting in a fall due to lack of physical assistance while ambulating.
Failure to immediately telephone emergency response (9-1-1) for a terminally ill resident receiving hospice services during a medical emergency not related to the expected course of the resident’s terminal illness, causing delayed emergency response.
Report Facts
Capacity: 6 Census: 3 Civil penalty: 500 Time lapse: 100

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the complaint investigation and delivered findings
Abigail BudacAdministratorFacility administrator interviewed during investigation
S1CaregiverCaregiver involved in the incident with resident R1
Maribeth SentyLicensing Program ManagerOversaw the complaint investigation

Inspection Report

Complaint Investigation
Census: 5 Capacity: 6 Deficiencies: 0 Date: May 9, 2024

Visit Reason
The visit was a case management inspection conducted to deliver complaint findings related to an incident report of a resident's fall with injury.

Complaint Details
The complaint involved an incident report of resident R1's fall with injury. The complaint was investigated and found not substantiated as the fall was not due to lack of supervision and medical care was timely.
Findings
The fall did not appear to be due to lack of supervision and the resident received timely medical care. No deficiencies were noted as a result of the inspection.

Report Facts
Capacity: 6 Census: 5

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the case management visit and delivered complaint findings
Abigaila BudacAdministratorNamed as facility administrator, but was unavailable during the visit

Inspection Report

Complaint Investigation
Census: 5 Capacity: 6 Deficiencies: 0 Date: May 9, 2024

Visit Reason
The inspection was conducted as a case management visit to deliver complaint findings related to an incident report of a resident's fall with injury.

Complaint Details
The visit was triggered by an incident report received on 2024-05-01 regarding a resident's fall with injury. The complaint was investigated and found not substantiated as no lack of supervision was identified.
Findings
The fall did not appear to be due to lack of supervision and the resident received timely medical care. No deficiencies were noted as a result of the inspection.

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the case management visit and delivered complaint findings.

Inspection Report

Annual Inspection
Census: 4 Capacity: 6 Deficiencies: 0 Date: Mar 27, 2024

Visit Reason
The inspection was an unannounced annual inspection conducted to evaluate the facility's compliance with health and safety regulations using the CARE inspection tool.

Findings
No deficiencies were cited during the inspection. The facility was found to be very clean, with no immediate health, safety, or personal rights violations observed. Resident files and staff files were complete.

Report Facts
Capacity: 6 Census: 4

Employees mentioned
NameTitleContext
Abigaila BudacAdministratorPresent to assist during the inspection and discussed hospice care plan levels of detail
Kevin MknellyLicensing Program AnalystConducted the annual inspection
Maribeth SentyLicensing Program ManagerNamed in the report header

Inspection Report

Annual Inspection
Census: 4 Capacity: 6 Deficiencies: 0 Date: Mar 27, 2024

Visit Reason
The inspection was an unannounced annual inspection conducted by Licensing Program Analyst Kevin Mknelly to ensure compliance with health and safety regulations using the CARE inspection tool.

Findings
The facility was found to be clean with no immediate health, safety, or personal rights violations observed. Resident and staff files were complete, and no deficiencies were cited during the inspection.

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the annual inspection and evaluation.
Abigaila BudacAdministratorFacility administrator present to assist during the inspection.

Inspection Report

Complaint Investigation
Census: 4 Capacity: 6 Deficiencies: 2 Date: Feb 21, 2024

Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-01-16 regarding staff restraining a resident and prohibiting resident visits, as well as allegations of medication mismanagement and inadequate feeding.

Complaint Details
The complaint investigation was substantiated for allegations that staff restrained a resident and prohibited resident visits. The allegations of medication mismanagement and inadequate feeding were unsubstantiated.
Findings
The investigation substantiated that staff restrained a resident using a weighted blanket tied in place and that visits were at times discouraged or limited by appointment, posing immediate and potential risks to resident rights. Allegations regarding medication mismanagement and inadequate feeding were found unsubstantiated due to lack of evidence.

Deficiencies (2)
Use of a weighted blanket tied and tucked to limit resident's movements constituted a restraint, violating postural support regulations.
Visits were discouraged or limited by appointment, violating residents' personal rights to receive visitors.
Report Facts
Facility capacity: 6 Census: 4 Deficiencies cited: 2 Plan of Correction due dates: 2

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the complaint investigation and delivered findings
Abigaila BudacAdministratorFacility administrator present during investigation and exit interview
Ildiko SoropanLead CaregiverMet with Licensing Program Analyst during investigation and involved in findings
Maribeth SentyLicensing Program ManagerNamed as Licensing Program Manager overseeing the investigation

Inspection Report

Complaint Investigation
Census: 4 Capacity: 6 Deficiencies: 2 Date: Feb 21, 2024

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 2024-01-16 regarding staff restraining a resident and prohibiting resident visits, as well as allegations of medication mismanagement and inadequate feeding.

Complaint Details
The complaint investigation was substantiated for allegations that staff restrained a resident with a weighted blanket and prohibited resident visits by discouraging or requiring appointments. The allegations of staff mismanaging medication and not ensuring adequate feeding were unsubstantiated.
Findings
The investigation substantiated that staff restrained a resident using a weighted blanket tied in place without family or hospice consent, and that visits were at times discouraged or limited by appointment, violating resident rights. Allegations of medication mismanagement and inadequate feeding were found unsubstantiated due to lack of evidence.

Deficiencies (2)
Use of postural supports including tying or limiting use of resident's hands or feet was not permitted; weighted blanket used as restraint.
Violation of personal rights by discouraging or limiting resident visits without proper cause.
Report Facts
Facility capacity: 6 Resident census: 4 Plan of Correction due date: Feb 22, 2024 Plan of Correction due date: Mar 6, 2024

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted complaint investigation and delivered findings
Abigaila BudacAdministratorFacility administrator present during investigation and exit interview
Ildiko SoropanLead CaregiverInterviewed during investigation regarding complaint findings

Inspection Report

Complaint Investigation
Census: 5 Capacity: 6 Deficiencies: 0 Date: Dec 5, 2023

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were verbally abusive toward residents.

Complaint Details
The complaint alleged verbal abuse by staff toward residents. The complaint was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
Findings
The investigation found that the facility met Title 22 requirements, was clean and well staffed, and that residents and families were very happy with care and interactions. The complaint was determined to be unfounded and dismissed.

Report Facts
Capacity: 6 Census: 5

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the complaint investigation and delivered findings
Abigaila BudocAdministratorMet with Licensing Program Analyst during investigation

Inspection Report

Complaint Investigation
Census: 5 Capacity: 6 Deficiencies: 0 Date: Dec 5, 2023

Visit Reason
This was an unannounced complaint investigation visit triggered by a complaint alleging that staff were verbally abusive toward residents.

Complaint Details
The complaint alleging verbal abuse by staff toward residents was investigated and found to be unfounded, meaning the allegation was false, could not have happened, or was without reasonable basis.
Findings
The investigation found that the facility met Title 22 requirements, was clean and well staffed, and that residents and families were very happy with care and interactions. The complaint was determined to be unfounded and dismissed.

Report Facts
Capacity: 6 Census: 5

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the complaint investigation and delivered findings
Abigaila BudocAdministratorMet with Licensing Program Analyst during investigation

Inspection Report

Annual Inspection
Census: 5 Capacity: 6 Deficiencies: 0 Date: Apr 26, 2023

Visit Reason
An unannounced visit was conducted to perform the required annual inspection of the facility.

Findings
The inspection found the facility to be operating within the scope of its license with no deficiencies observed or cited. The facility was clean, well-maintained, and compliant with safety and care standards.

Report Facts
Hospice residents: 4

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the inspection visit
Abigaila BudacAdministratorFacility administrator contacted during inspection
Maribeth SentyLicensing Program ManagerNamed in report header

Inspection Report

Annual Inspection
Census: 5 Capacity: 6 Deficiencies: 0 Date: Apr 26, 2023

Visit Reason
An unannounced required annual inspection was conducted to evaluate compliance with licensing requirements.

Findings
The facility was found to be operating within the scope of its license with no deficiencies observed or cited. The interior and exterior were inspected, including resident rooms, bathrooms, and kitchen, all found clean and in good repair.

Report Facts
Hospice residents: 4

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the inspection visit
Abigaila BudacAdministratorFacility administrator contacted during inspection

Inspection Report

Annual Inspection
Census: 6 Capacity: 6 Deficiencies: 0 Date: Mar 18, 2022

Visit Reason
The inspection was a Required-1 Year unannounced visit to conduct an annual inspection focusing on infection control compliance.

Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the inspection and authored the report.
Abigaila BudacAdministratorFacility administrator mentioned in the report.

Inspection Report

Annual Inspection
Census: 6 Capacity: 6 Deficiencies: 0 Date: Mar 18, 2022

Visit Reason
The inspection was an unannounced Required-1 Year Inspection utilizing the infection control domain to ensure compliance with health and safety regulations.

Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the inspection and authored the report
Abigaila BudacAdministratorFacility administrator present during inspection

Inspection Report

Annual Inspection
Census: 5 Capacity: 6 Deficiencies: 0 Date: Aug 26, 2021

Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on infection control to ensure compliance with health and safety regulations.

Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the Required-1 Year Inspection and authored the report.
Abigaila BudacAdministratorFacility Administrator present during the inspection.

Inspection Report

Annual Inspection
Census: 5 Capacity: 6 Deficiencies: 0 Date: Aug 26, 2021

Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure compliance with health and safety regulations.

Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.

Employees mentioned
NameTitleContext
Kevin MknellyLicensing Program AnalystConducted the inspection and authored the report
Abigaila BudacAdministratorFacility administrator present during the inspection

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