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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200718
Report Date: 02/06/2024
Date Signed: 02/06/2024 12:41:47 PM

Document Has Been Signed on 02/06/2024 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
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:
02/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rosalinda Amacan, AdministratorTIME COMPLETED:
01:21 PM
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On 2/06/2024 Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced required 1 year inspection. LPA met with administrator, Rosalinda Amacan.

LPA toured the facility including but not limited to four (4) bedrooms, two (2) bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water present at this facility. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 120.0 degrees F. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene were available for clients. All four (4) clients are bedridden with approved fire clearance from Fremont Fire Department. Three (3) clients are on G tube and one (1) is on J tube feeding. Fire extinguisher last serviced on 2/6/2024. Disaster drill last conducted 1/23/2024. First aid kit inspected and complete. Emergency disaster plan posted and dated 5/16/2023.

Four (4) client records were reviewed at 9:30 am. All clients had a current needs and service plan, admissions agreement, and medical assessment on file. Four (4) staff records reviewed at 9:05 am. All staff were fingerprint cleared and associated to the facility. Staff reviewed had current first aid/ CPR and in good health to perform job functions. P&I reviewed for three (3) clients. P&I was intact and not commingled with facility funds.

No deficiencies, exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2024
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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