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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 01:55:09 PM

Document Has Been Signed on 09/22/2023 01:55 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:LICENSEE ALBERTINA "TINA" CAMACLANGTIME COMPLETED:
02:30 PM
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On 09/22/2023 at 9:30 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced for a case management visit concerning the 08/06/2023 COVID-19 outbreak at the facility. 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 interviewed the Licensee and reviewed documentation demonstrating that she had fully complied with reporting requirements for both the Department and for Contra Costa Public Health during the COVID-19 outbreak on 08/06/2023. Additionally, that she had properly cared for resident R1 when she was infected with COVID-19 and then when she was later hospitalized.

No citations issued during this visit.

Exit interview was conducted with Licensee. 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)
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