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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200624
Report Date: 01/17/2025
Date Signed: 01/17/2025 05:11:13 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/10/2024 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241210090009
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:
01/17/2025
UNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Licensee Tina CamaclangTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not check on resident according to care plan.
Staff did not prevent resident from accessing construction area.
INVESTIGATION FINDINGS:
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On 1/17/2024 at 4:45 PM, Licensing Program Analyst (LPA) James Sampair arrived at the facility unannounced to deliver the findings of the investigation regarding the allegations above. Upon entry in the facility, the LPA stated the purpose of the visit to Licensee Tina Camaclang.

The complaint alleges that staff did not check on resident according to care plan.
The LPA reviewed resident R1 documentation, including Physician's Reports, Care Plans, Medication Records, and Admission Agreement from the facility and copies of the Sheriff's Report, letter from the Coroner, and R1's death certificate. The LPA interviewed witness W1 and the Licensee. The data collected does not confirm the allegation.

Continued on LIC 9099-C . . .
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20241210090009
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 INC
FACILITY NUMBER: 079200624
VISIT DATE: 01/17/2025
NARRATIVE
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. . . Continued from LIC 9099

The complaint alleges that staff did not prevent resident from accessing construction area.
The LPA reviewed resident R1 documentation, including Physician's Reports, Medication Records, and Admission Agreement from the facility and copies of the Sheriff's Report, letter from the Coroner, and R1's death certificate. The LPA interviewed witness W1 and the Licensee. The data collected does not confirm the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2