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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200718
Report Date: 02/18/2025
Date Signed: 02/18/2025 04:46:50 PM

Document Has Been Signed on 02/18/2025 04:46 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/
DIRECTOR:		AMACAN, ROSALINDA BFACILITY TYPE:
734
ADDRESS:40153 SCHOOL COURTTELEPHONE:
(510) 384-9446
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 4CENSUS: 4DATE:
02/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Rosalinda Amacan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 02/18/2025 at 1:35 PM, Licensing Program Analyst (LPA) Patricia Manalo arrived unannounced to conduct a Required 1 Year Inspection. LPA met with RN Staff, Eduardo Lizardo, who phoned the Administrator and explained the purpose of the visit. Administrator, Rosalinda Amacan, arrived shortly after. The fire clearance is approved for four (4) all non-ambulatory, of which four may be bedridden.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which all bedrooms are occupied by the clients, one ADA bathroom, and one staff bathroom. There are no bodies of water. A comfortable temperature for clients is maintained at 75 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature was measured at 105.1 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene's was available for clients.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 02/07/2025. Fire Drill was conducted on 01/15/2025. First aid kit was observed to be complete.

At 2:17 PM, 4 of clients records were reviewed. At 2:51 PM, 4 staff records were reviewed and 4 of 4 have current first aid training and are associated to the facility. LPA reviewed clients' P&I money with log and there was no discrepancies observed. LPA reviewed two samples of clients' medications. All records were observed to be complete and up to date.

Continue to LIC809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AMATO HOME
FACILITY NUMBER: 019200718
VISIT DATE: 02/18/2025
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Continue from LIC809...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 02/25/2025:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
Liability Insurance
Auto Insurance
Auto Registration
Drivers License

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 2:05 PM, LPA observed the left side of the gate with a lock. Civil penalty of $500 is being assessed.


At 4:15 PM, LPA observed that C2 and C3 does not have one of their PRN medications at the facility.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/18/2025 04:46 PM - It Cannot Be Edited


Created By: Patricia Manalo On 02/18/2025 at 04:24 PM
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: 02/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

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 the left side gate without fire clearance for locked parameter which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/19/2025
Plan of Correction
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Administrator removed the locked screw from the side gate during today's visit. Deficiency cleared.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/18/2025 04:46 PM - It Cannot Be Edited


Created By: Patricia Manalo On 02/18/2025 at 04:24 PM
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: 02/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

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 in not having C2 and C3's PRN medication in the facility which poses a potential health and safety risk to persons in care.
POC Due Date: 02/26/2025
Plan of Correction
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Administrator agrees to order the PRN medication for the clients and send proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


LIC809 (FAS) - (06/04)
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