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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200624
Report Date: 09/22/2023
Date Signed: 09/22/2023 01:56:43 PM

Document Has Been Signed on 09/22/2023 01:56 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
OAKLAND ASC, 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:
09/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:LICENSEE ALBERTINA "TINA" CAMACLANGTIME COMPLETED:
02:30 PM
NARRATIVE
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On 09/22/2023 at 9:30 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced at facility for required annual inspection. Upon entering facility, LPA stated purpose of visit to staff member Evelyn Gordon who called Licensee Tina Camaclang. The Licensee arrived at approximately 10:00 AM.

During the Inspection, the LPA inspected the facility inside and outside. LPA observed that the facility has a sufficient supply of food: 2 days perishable and 7 days nonperishable. A comfortable inside temperature of 72.5 degrees F was maintained. The facility was clean and the staff attentive to residents' needs.

2 Type-B citations were issued during the inspection (details in LIC809-D).

The Required Annual Inspection is incomplete. The LPA will return unannounced to complete the inspection at a later date and time.

Exit interview conducted with Licensee and a copy of this report was provided via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2023
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 09/22/2023 01:56 PM - It Cannot Be Edited


Created By: James Sampair On 09/22/2023 at 12:03 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: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

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. The fire extinguisher was stored in a hallway closet and the staff person had to search to find it, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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In accordance with the 2013 California Fire Code 906.1, the Licensee shall obtain and store at least one 2A:10B:C rated fire extinguisher that has been mounted in a visible and accessible location with the top of the extinguisher no higher than 5 feet. The maximum travel distance to an extinguisher shall not be more than 75 feet. Fire extinguishers shall be serviced annually with a service tag attached.
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:Bennett Fong
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/22/2023 01:56 PM - It Cannot Be Edited


Created By: James Sampair On 09/22/2023 at 12:54 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: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, because only 1 of the 4 required drills had been completed in the past year. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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The Licensee shall complete an emergency drill and complete documentation of its completion and send proof or attestation of its completition to LPA on or before due date.
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:Bennett Fong
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023


LIC809 (FAS) - (06/04)
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