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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610207
Report Date: 12/28/2022
Date Signed: 12/28/2022 02:19:08 PM

Document Has Been Signed on 12/28/2022 02:19 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:AMORE VILLAFACILITY NUMBER:
197610207
ADMINISTRATOR:MELKONYAN, MARIYAFACILITY TYPE:
740
ADDRESS:8455 SPRINGFORD DRTELEPHONE:
(818) 425-4975
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 6CENSUS: 2DATE:
12/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Asya AkopyanTIME COMPLETED:
02:30 PM
NARRATIVE
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At approximately 12:30 p.m. on 12/28/2022 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit for complaint number 31-AS-20221220142848. During a record review at approximately 1:15 p.m., LPA discovered missing resident records.

The facility did not maintain the LIC 602A, LIC 603, LIC 625, or LIC 601 for Resident #1 (R1).

The facility did not maintain the LIC 603 or LIC 625 for Resident #2 (R2).

The deficiency is addressed on this case management report.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2022
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 2
Document Has Been Signed on 12/28/2022 02:19 PM - It Cannot Be Edited


Created By: Nicholas Reed On 12/28/2022 at 01:39 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: AMORE VILLA
FACILITY NUMBER: 197610207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2023
Section Cited
CCR
87506(a)

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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
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Licensee will produce all required forms for all residents and send proof of correction by the PIOC due date.
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 residents, which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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:Cassandra Harris
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022


LIC809 (FAS) - (06/04)
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