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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200624
Report Date: 09/30/2024
Date Signed: 10/01/2024 07:30:17 AM

Document Has Been Signed on 10/01/2024 07:30 AM - 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/
DIRECTOR:		CAMACLANG, ALBERTINAFACILITY TYPE:
740
ADDRESS:2203 TICE VALLEY BLVDTELEPHONE:
(925) 705-7931
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY: 6CENSUS: 4DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Caregiver Maribel ZumelTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 9/30/2024 at 12:15 PM, Licensing Program Analysts (LPAs) James Sampair and David Doidge arrived unannounced to conduct the Required Annual Inspection. Upon entry, LPAs stated the purpose of the visit to Caregiver Maribel Zumel. Administrator Tina Camaclang arrived at 1:05 PM.

The LPAs inspected the interior and exterior of the facility. The inspection of the physical plant included the kitchen, dining area, restrooms, community living spaces, resident rooms, storage areas, and the grounds of the facility. More than the required minimum of 7 days of nonperishable and 2 days of perishable foods were appropriately stored. The hot water temperature in the bathroom was 109 degrees at 12:25 PM. The room temperature of the living room was 72 degrees at 12:30 PM. Fire Extinguisher date was 09/11/2023. The carbon monoxide and smoke detectors were fully operational.

The LPAs observed required postings in the facility, including the Residential Care Facility for the Elderly Complaint Poster, Ombudsman and Personal Rights posters, and the Theft and Loss Policy. An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations.

One type A and one type B citations were issued during the inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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 10/01/2024 07:30 AM - It Cannot Be Edited


Created By: James Sampair On 09/30/2024 at 01:49 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: 09/30/2024

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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Based on observation, the licensee did not comply with the section cited above as nunlocked garage door from kitchen giving residents access to Fabuloso, Downy Laundry detergent, and 409 cleaner which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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Install lock on garage door and provice proof to LPAs.
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: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/01/2024 07:30 AM - It Cannot Be Edited


Created By: James Sampair On 09/30/2024 at 01:49 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: 09/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 as hose was left on backyard sidewalk causing a trip hazard which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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corrected during visit.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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3
4
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: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3