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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200624
Report Date: 09/16/2022
Date Signed: 09/16/2022 04:48:49 PM

Document Has Been Signed on 09/16/2022 04:48 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: 5DATE:
09/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Tina CamaclangTIME COMPLETED:
05:15 PM
NARRATIVE
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On 9/16/22 at 1:00 PM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon arrival, LPA explained the purpose of the visit to staff. Administrator Tina Camaclang arrived shortly after LPA had toured the facility inside and outside.

Facility has an infection control plan in place that they are following. The designated infection control leader is the administrator. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch thermometer. Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. COVID-19 signs were posted to promote hand washing, cough/sneeze etiquette and physical distancing.

The temperature inside of the facility was 75.2 and the hot water temperature was 110 degrees, which were in the safe temperature range. An administrator is on site at least the required 20 hour minimum each week to oversee business operations.

Facility cited for 2 Type A and 1 Type B deficiencies (refer to LIC 809-D).

Exit interview conducted, copy of Appeal Rights, and a copy of this report provided via email
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 09/16/2022 04:48 PM - It Cannot Be Edited


Created By: James Sampair On 09/16/2022 at 03:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CASA AMORE CARE HOME INC
FACILITY NUMBER: 079200624

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above with an unlocked knife drawer in the kitchen and cleaners stored in unlocked cabinets in kitchen and garage, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2022
Plan of Correction
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Licensee shall lock all of the drawers and cabinets storing potentially dangerous items or move the items to a safe storage location if the lock is broken on or before the due date.
Type A
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in all refrigerators and freezers where food was stored without a date on it identifying the date it was opened, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2022
Plan of Correction
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Licensee shall date and securely close all foods stored in the refrigerators and the freezers.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/16/2022 04:48 PM - It Cannot Be Edited


Created By: James Sampair On 09/16/2022 at 03:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CASA AMORE CARE HOME INC
FACILITY NUMBER: 079200624

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above, with non-working and unused locks where potentially dangerous items were stored, inadequate compliance with COVID-19 guidance, and the fire extinguisher not being mounted where visible which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2022
Plan of Correction
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The licensee shall: (1) Repair or replace all non-working and unused locks where potentially dangerous items are stored. (2) Mount the fire extinguisher in a location where it is visible and accessible. (3) Post a minimum of 1 proper hand washing signs at every sink in the facility AND post a minimum of 10 additional COVID-19 related signs including those with social distancing and cough / sneeze etiquitte AND retrain staff concerning cloth towel use.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022


LIC809 (FAS) - (06/04)
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