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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200624
Report Date: 10/15/2024
Date Signed: 10/15/2024 12:49:54 PM

Document Has Been Signed on 10/15/2024 12:49 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/
DIRECTOR:		CAMACLANG, ALBERTINAFACILITY TYPE:
740
ADDRESS:2203 TICE VALLEY BLVDTELEPHONE:
(925) 705-7931
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY: 6CENSUS: 4DATE:
10/15/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Caregiver Maribel ZumelTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 10/15/2024 at 9:00 AM, Licensing Program Analysts (LPAs) James Sampair and David Doidge arrived unannounced to conduct a Case Management - Annual Continuation inspection to complete the Required Annual Inspection that was partially completed on 9/30/2024. Upon entry, LPAs stated the purpose of the visit to Caregiver Gina Longoria. Licensee Tina Camaclang arrived at approximately 10:00 AM.

The LPAs completed a review of the facility records. The LPAs reviewed the records of 5 residents and 5 staff members. The LPAs interviewed 4 staff members.

Administrator will provide LPA copies of the following documents by 10/22/2024:
1. LIC 308 Designation of Facility Responsibility
2. LIC 500 Personnel Report
3. $3M Liability Insurance certificate

1 B-Type citation 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: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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Document Has Been Signed on 10/15/2024 12:49 PM - It Cannot Be Edited


Created By: James Sampair On 10/15/2024 at 12:29 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: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

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 for ALL staff members, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
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On or before due date, licensee shall obtain a LIC 503 Health Screen with TB test report for EVERY staff member.
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: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
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