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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880552
Report Date: 02/15/2022
Date Signed: 02/15/2022 05:05:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/15/2020 and conducted by Evaluator Jennifer Semin
COMPLAINT CONTROL NUMBER: 18-AS-20200515090558
FACILITY NAME:CURA AMOREFACILITY NUMBER:
331880552
ADMINISTRATOR:VITO, ANNA BELLAFACILITY TYPE:
740
ADDRESS:2394 MONTEREY PENINSULA DRTELEPHONE:
(626) 423-9194
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY:6CENSUS: 4DATE:
02/15/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Eddie DabuTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility is retaining resident requiring a higher level of care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to the facility to deliver the findings for the above complaint allegation. LPA met with Caregiver, Eddie Dabu. Administrator Anna Bella Vito was notified via telephone.
The investigation consisted of interviews and record review. The allegation, Facility is retaining resident requiring a higher level of care. Facility staff stated staff did give R1 their medication and did check their blood sugar. Staff stated staff did not take R1 to any doctor or lab appointments. Staff stated R1 was transported to the hospital per physician’s request and admitted to a higher level of care. R1 could not corroborate or refute the allegation.
Based on interviews and documentation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 1) is being cited on the attached LIC9099D.
An exit interview was conducted where this report, LIC9099D, and appeal rights were discussed and provided to Ms.Vito via telephone and Mr. Dabu
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 18-AS-20200515090558
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CURA AMORE
FACILITY NUMBER: 331880552
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2022
Section Cited
CCR
87468.2(a)(4)
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To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This regulation was not met as evidence by: staff did not notify doctor or representative when R1 had a change in condition that required
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Licesnee shall read the reguakltion in its entirety and submit a statement of understandiing to CCL by the POC due date of 2/16/2022.
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a higher level of care for R1. This poses an immediate risk to residents 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.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2