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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200624
Report Date: 12/09/2021
Date Signed: 12/09/2021 01:58:46 PM

Document Has Been Signed on 12/09/2021 01:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 INCFACILITY NUMBER:
079200624
ADMINISTRATOR:CAMACLANG, ALBERTINAFACILITY TYPE:
740
ADDRESS:2203 TICE VALLEY BLVDTELEPHONE:
(925) 705-7931
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY: 6CENSUS: 6DATE:
12/09/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jennyfe LaganaTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) James Sampair conducted a Plan of Correction (POC) inspection concerning the LIC809-D citation issued by LPA on 11/18/21. Upon arrival, LPA explained the purpose of the visit with Staff Member Jennyfe Lagana who showed that the fire extinguisher had been serviced 3 days after the POC in November.

LPA then inspected the facility inside and outside. During the inspection, he observed that 2 of the 2 staff present were wearing face masks during visit and that they continue to follow the COVID-19 infection control measures in accordance with the Department and local public health requirements. The facility room temperature was maintained at a comfortable level and a certified administrator is on site more than the minimum of 20 hours a week to oversee proper business operation.

The POC was cleared during this visit and no deficiencies cited during this visit. Exit interview conducted and a copy of this report was provided to the administrator.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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