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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200624
Report Date: 10/28/2021
Date Signed: 10/28/2021 02:21:56 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/03/2020 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200703120450
FACILITY NAME:CASA AMORE CARE HOME INCFACILITY NUMBER:
079200624
ADMINISTRATOR:CAMACLANG, ALBERTINAFACILITY TYPE:
740
ADDRESS:2203 TICE VALLEY BLVDTELEPHONE:
(650) 722-3521
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 6DATE:
10/28/2021
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Genny Flores, House ManagerTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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-Staff failed to abide by the Admission Agreement
-Staff mishandled resident's personal belongings
INVESTIGATION FINDINGS:
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On 10/28/2021 at 2:05PM, Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced continuing complaint visit, meeting with the House Manager Genny Flores. Administrator was not at the facility and authorized Genny to sign and receive report.

The Department conducted an investigation into the allegations per interviews and records review. Regarding the allegation that staff failed to abide by the Admission Agreement, the Department found that there was a financial dispute between the facility and the subject resident’s Responsible Party pertaining to a refund after the resident was moved out of facility past the 30 days notice given to facility. Upon review of the Admission Agreement, there was no language that addressed the specific circumstances of the issue.




Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20200703120450
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CASA AMORE CARE HOME INC
FACILITY NUMBER: 079200624
VISIT DATE: 10/28/2021
NARRATIVE
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Per the allegation that staff mishandled resident’s personal belongings (a wheelchair and a red walker), the Department found that the facility had completed a detailed Personal Property and Valuables list that included the subject items at the time of move in, and it was provided to the subject resident’s Responsible Party - and signed off by the Responsible Party - at the time of move-out. There was insufficient information available to verify whether the correct wheelchair and walker had been returned.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred; therefore the allegations are Unsubstantiated.

Exit interview conducted with House Manager Genny Flores and a copy of this report was provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2