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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200718
Report Date: 08/11/2023
Date Signed: 08/11/2023 12:41:40 PM

Document Has Been Signed on 08/11/2023 12:41 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
OAKLAND ASC, 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:
08/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:AMACAN, ROSALINDA B- Administrator TIME COMPLETED:
12:50 PM
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On 8/11/2023, at 9:00 AM. Licensing Program Analyst (LPAs) L. Fici arrived unannounced to conduct a Case Management Visit. LPA was greeted by Rosalinda, Amacan, Administrator (ADM) and explained the purpose of today’s visit.

LPA received an incident report which occurred on 6/20/2023, regarding a death in the facility. During visit, LPA conducted record review and obtained the following documents: Nurse notes (June 2023), doctors notes (June 2023), Physicians order for medication, Medication administrative record (MAR), Physicians report, Do not Attempt Resuscitation (DNR) order, and Individualized health care plan (IHCP).

LPA conducted interviews with 3 staff at 10:33 AM. Both S1 and S2 stated that C1 was given her medication for muscle spasms; S1 mentioned at 6:45pm C1’s medication was given. Staff follows physician’s order for medication. S1 informed LPA that C1 was doing fine and there were no concerns. S1 evaluated client after C1 was spastic; C1’s spasms were not bad during the time. S1 and S3 stated C1 has spasms every day. S2 stated that C1 became spastic after a few bites of her food, then S2 left C1 unattended to take C1’s food tray to the kitchen to allow client to relax so staff can feed her later. C1 does not need one on one care. S1 stated that S2 stopped feeling C1 and left C1 unsupervised for less than a minute to put C1’s food tray away so staff can feed her later. S1 told S2 to turn on C1’s fan. S2 went into C1’s room and found C1 unresponsive. S1 called 911 at 8:25PM on 6/20/2023 and was advised by 911 dispatch to perform CPR on C1. C1 has a Do not Attempt Resuscitation (DNR) order on file.

No deficiencies cited during visit.

LPA will return at a later time if necessary.Exit interview conducted with ADM and copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2023
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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