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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200718
Report Date: 03/04/2022
Date Signed: 03/04/2022 11:29:44 AM

Document Has Been Signed on 03/04/2022 11:29 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:AMATO HOMEFACILITY NUMBER:
019200718
ADMINISTRATOR:AMACAN, ROSALINDA BFACILITY TYPE:
734
ADDRESS:40153 SCHOOL COURTTELEPHONE:
(510) 384-9446
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 4CENSUS: 4DATE:
03/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Rosalinda Amacan, AdministratorTIME COMPLETED:
11:45 AM
NARRATIVE
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On 3/4/2022 at 8:30AM, Licensing Program Analysts (LPAs) G. Luk and L. Fici arrived unannounced to conduct an Infection Control Inspection. LPAs met with Nurse, Lynette Ocon and explained the purpose of the visit. Administrator, Rosalinda Amacan arrived 30 minutes later.

Upon entry, LPA's temperature was checked and was asked screening questions. LPAs observed hand sanitizer at screening station. LPAs toured facility including but not limited to bedrooms, bathrooms, common areas, kitchen, garage, and outdoor area. LPAs observed cough etiquette, physical distancing, and signs & symptoms posted in the common areas. All hand washing stations were equipped with soap, paper towel and garbage can with a lid. Hand washing signs were posted at sinks and bathrooms.

During record review, LPAs observed visitors log and temperature log for staff and clients. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed PPE, food, and paper supplies are sufficient. LPAs reviewed 3 staff's training documents and observed that they had DSP training, first aid, and CPR on file.

At 8:50AM, LPAs observed unlocked cleaning supplies under the kitchen sink and unlocked knives drawer. Staff locked drawer and cleaning supplies during inspection.

At 9:00AM, LPAs observed unlocked medications in the refrigerator. Staff locked the medications in the lockbox during inspection.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2022
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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Document Has Been Signed on 03/04/2022 11:29 AM - It Cannot Be Edited


Created By: Grace Luk On 03/04/2022 at 10:41 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AMATO HOME
FACILITY NUMBER: 019200718

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 by having unlocked knives and cleaning supplies which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/05/2022
Plan of Correction
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Staff locked knives drawer and put away cleaning supplies during visit.

Deficiency cleared during inspection.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication 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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4
Based on observation, the licensee did not comply with the section cited above by having unlocked medications in the refrigerator which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/05/2022
Plan of Correction
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Staff locked medications in lockbox during visit.

Deficiency cleared during inspection.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022


LIC809 (FAS) - (06/04)
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