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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880552
Report Date: 11/17/2022
Date Signed: 11/17/2022 02:21:02 PM

Document Has Been Signed on 11/17/2022 02:21 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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: 6DATE:
11/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Licensee- Annabella Vito TIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Victoria Chitgian made an unannounced visit to the facility to conduct a case management visit to follow up on a past complaint. LPA met with licensee Annabella Vito.

The case management visit consisted of conducting staff and resident interviews in regards to complaint #18-AS-20210318100048.

Interviews with staff revealed no inappropriate behavior has been seen or heard of towards the residents from staff. Interviews with residents confirm they enjoy living here. Resident 1(R1) stated they are given excellent care. Resident 2 (R2) stated he has not seen or heard any concerning or inappropriate acts from staff toward resident. Resident 4 (R4) stated the staff are very nice, helpful people. Staff 1(S1) stated he has not seen, heard or witnessed a staff inappropriately handle a resident.

During this visit, LPA observed deficiencies not related to the case management visit.

During the visit LPA completed a walk through the facility and reviewed documentation. While investigating records, LPA observed Staff 2 (S2) did not have fingerprint clearance. This poses an immediate health and safety risk to residents in care. LPA reviewed documents that showed S2 worked at the facility for two (2) days. Documentation of Personnel Records (LIC 501) for S2 show the date of employment began November 15, 2022.

One(1) deficiency was issued per Title 22 Division 6 of the California Code of Regulations. A Civil Penalty of $200 was assessed on 11/17/2022. Refer to LIC809-D for deficiencies cited.

An exit interview was conducted, and copy of this report (LIC809), LIC 809-D, LIC421BG, and appeal rights was provided to licensee Annabella Vito.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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 11/17/2022 02:21 PM - It Cannot Be Edited


Created By: Victoria Chitgian On 11/17/2022 at 10:09 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CURA AMORE
FACILITY NUMBER: 331880552

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2022
Section Cited
CCR
87355(e)(1)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
The licensee did not comply with the section cited above as:
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Licensee shall submit a Criminal Record Clearance to Community Care Licensing for Staff 2 by the Plan of Correction (POC) date of 11/18/2022. Proof of submission to be submitted to LPA Chitgian.
Type A
11/17/2022
Section Cited
CCR
87355(e)(1)

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Staff 2 did not have criminal clearance to work at the facility which poses an immediate 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:Efren Malagon
LICENSING EVALUATOR NAME:Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022


LIC809 (FAS) - (06/04)
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