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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609345
Report Date: 08/16/2022
Date Signed: 08/16/2022 01:23:56 PM

Document Has Been Signed on 08/16/2022 01:23 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
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:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rita Morales,AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Shira Stamps met with Administrator Rita Morales for an unannounced one (1) year Required visit for this facility.

LPA arrived at 10:35 am and was greeted by caregiver Adelaida Salazar. All residents were observed to be in their rooms sleeping, watching TV and/or resting. The Administrator arrived at 11:00 am and informed her of the purpose of the visit.

Infection control: LPA reviewed facility mitigation plan (approved on 03/06/21) to make sure licensee was following current infection control recommendations. Upon arrival LPA was not screened by the caregiver LPA was asked to sign-in and sanitizer was available.

A tour of the physical plant was conducted with Administrator at 11:12 am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying six (6) residents. facility is Fire Cleared for six (6) non-ambulatory and has a hospice waiver for four (4).

Food Inspection
LPA conducted tour at the kitchen around 11:15 am observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp object being locked and inaccessible to residents in care. LPA observed medications accessible to residents in care in a kitchen cabinet. The Administrator immediately locked the medications in the hallway medications closet.

CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CASA AMORE
FACILITY NUMBER: 197609345
VISIT DATE: 08/16/2022
NARRATIVE
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Living and dining
LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 73°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 11:28 am. There are two (2) fire extinguishers, one (1) is located in the kitchen and one (1) is located in the garage. The Fire extinguishers were observed to be full.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident. LPA tested the exit doors auditory system, and it was observed to be operational for each room.

Bathrooms
At 11:26 am LPA observed all bathrooms to have non-skid matts, grab bars, and the appropriated wash your hands signs posted. Hot water was tested and measured within regulation at 120.0 degrees F.

Laundry/Garage
LPA observed chemicals/hazardous items in the locked laundry room. The garage is attached to the facility and connected to the locked laundry room. LPA observed 30-day supply of PPE, extra storage of items, and an extra refrigerator. Medications are kept in the refrigerator and are inaccessible to residents in care.

Physical environment
LPA toured the outside area of the facility at 11:27 am. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Administrative: LPA collected the LIC.500, resident roster, hospice waiver, and criminal record clearance. Annual fee is due 8/18/22. LPA requested the infection control plan. LPA requested fire clearance for bedridden resident since the fire clearance does not show the facility is cleared for bedridden residents.

An exit interview was conducted, citations and civil penalty issued. A copy of this report and appeal rights were given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/16/2022 01:23 PM - It Cannot Be Edited


Created By: Shira Stamps On 08/16/2022 at 12:43 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: 08/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
87202(a) Fire Clearance All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department… Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review the licensee did not comply with the section cited above in that the facility has one bedridden resident and the fire clearance does not have approval for bedridden residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2022
Plan of Correction
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The Administrator stated they will provide the previously obtained fire clearance that shows they were approved for bedridden residents, or if not found they will obtain bedridden clearance from the fire department and provide the LPA with verification of appointment set by the POC due date.
Type A
Section Cited
CCR
87465(h)(2)

87465 (h)(2) Incidental Medical and Dental Care Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 in that medications were found in the unlocked kitchen cabinet, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2022
Plan of Correction
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The Administrator stated staff will be provided in house training on locking away all medications. Training material and signatures of all staff that have completed the training will be sent to the LPA by the POC due date.
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:Shira Stamps
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/16/2022 01:23 PM - It Cannot Be Edited


Created By: Shira Stamps On 08/16/2022 at 01:02 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: 08/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)

87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and as evidenced by safe and effective job performance.

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 in that staff did not screen LPA for symptoms of COVID 19 upon entry, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2022
Plan of Correction
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Licensee/Administrator and all staff will attend infection control training to be provided by an individual trained in infection control. Proof of training will be provided to LPA by the POC due date.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Shira Stamps
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022


LIC809 (FAS) - (06/04)
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