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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002766
Report Date: 11/13/2023
Date Signed: 11/13/2023 11:24:59 AM

Document Has Been Signed on 11/13/2023 11:24 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CASA DE AMORFACILITY NUMBER:
045002766
ADMINISTRATOR:SERRANO, NORAFACILITY TYPE:
735
ADDRESS:162 HAMMON PARKTELEPHONE:
(530) 403-9510
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY: 4CENSUS: DATE:
11/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nora Serrano - administratorTIME COMPLETED:
11:30 AM
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11/13/2023 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Darlene Mehew ( 6009563735 Exp. 12/23/2023 ) and explained the purpose of the visit.

LPA Knight and the administrator toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to four (4) client rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. 2 of 3 staff files reviewed had transfer requests submitted but the staff were not associated to facility. Administrator agrees to complete the association of these staff to the facility immediately. These staff are associated to other facilities that are under the same licensee..

There is a schedule of recreational activities planned for the clients. Bedding, linens, and towels for clients were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the clients. Medication is locked in a cabinet.

The facility was observed to be at a comfortable temperature. Hot water measured between 105 – 120 degrees F. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and were inspected in December 2022 and are due for inspection this month.. Smoke detectors are all operational. No pools/bodies of water are on premises. No firearms are on premises. The facility has been conducting fire drills monthly.

A deficiency is being cited as a result of today’s inspection and is included on the attached LIC9099-D.

Exit interview conducted and copy of report was provided to administrator Nora Serrano.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2023
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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Document Has Been Signed on 11/13/2023 11:24 AM - It Cannot Be Edited


Created By: Rebecca Knight On 11/13/2023 at 11:19 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CASA DE AMOR
FACILITY NUMBER: 045002766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(12)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 3 staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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2 of 3 staff files reviewed had transfer requests submitted but the staff were not associated to facility. Administrator agrees to complete the association of these staff to the facility immediately. These staff are associated to other facilities that are under the same licensee.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023


LIC809 (FAS) - (06/04)
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