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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200718
Report Date: 09/29/2022
Date Signed: 09/29/2022 12:44:10 PM

Document Has Been Signed on 09/29/2022 12:44 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, 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: 3DATE:
09/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Care staff, Lynette OconTIME COMPLETED:
12:50 PM
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On today’s date 9/29/2022, at 11:40 AM. Licensing Program Analyst (LPAs) L. Fici and C. Lin arrived unannounced to conduct a Case Management Visit. LPAs was greeted by care staff, Lynette Ocon at the front door entrance. Administrator, Rosealinda Amacan gave consent to care staff to sign the report in her behave.

LPA received an incident report which occurred on 9/10/2022, regarding a death in the facility. LPAs conducted record review with Staff (S1). C1 has a DNR on file and was placed on hospice care dated 8/17/2022. Facility has a Hospice order to place C1 on hospice. LPAs verified the cause of death with S1. LPAs observed staff following hospice order, monitoring C1, and documenting change of condition daily.

No deficiencies cities during visit.

Exit interview conducted with care staff, and report provided
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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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