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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609345
Report Date: 08/19/2021
Date Signed: 08/20/2021 07:42:01 AM

Document Has Been Signed on 08/20/2021 07:42 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CASA AMOREFACILITY NUMBER:
197609345
ADMINISTRATOR:MORALES, RITAFACILITY TYPE:
740
ADDRESS:44124 WESTRIDGE DRIVETELEPHONE:
(661) 289-0288
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 6DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Rita Morales, staff Adelaida, SofiaTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angelica Arambulo conducted an unannounced required annual visit. LPA was greeted by staff and temperature check was done. The administrator Rita Morales was contacted and arrived at facility.

The LPA observed that there were 6 residents. There are 2 residents on hospice and one on home health.

The two staff working were not associated to the facility and staff #1 Sophia Gonzalez did not have a live scan according to Administrator Rita Morales. LPA will be emailing signage required for covid 19. Administrator is signed on to receiving PINS and will keep updated on Department of Public Healths protocol o n Covid 19.

The report was signed, Copy shall be emailed to administrator. POC instructions were given and appeal shall be emailed. The administrator was requested to updated staff schedule, register of residents and emergency disaster plan.

Exit interview conducted.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Angelica Arambulo
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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 08/20/2021 07:42 AM - It Cannot Be Edited


Created By: Angelica Arambulo On 08/19/2021 at 01:58 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA AMORE
FACILITY NUMBER: 197609345

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)
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:

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 staff 1 Sophia Gonzalez (her aunt) and staff 2 Adelaida Salazr Rueda] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2021
Plan of Correction
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Administrator Rita Morales agreed to have staff finger print associated and cleared.
Type A
Section Cited
CCR
87412(a)(13)
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: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review the administrator admitted to not comply with the section cited above for one staff Sophia Gonzalez who did not have a live scan, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2021
Plan of Correction
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Administrator shall have staff finger printed prior to working at the facility. A Immediate Civil Penalty is assessed for staff not finger print or associated to the faciity.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Angelica Arambulo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2021


LIC809 (FAS) - (06/04)
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