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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609345
Report Date: 11/27/2023
Date Signed: 11/27/2023 11:32:08 AM


Document Has Been Signed on 11/27/2023 11:32 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:CASA AMOREFACILITY NUMBER:
197609345
ADMINISTRATOR:MORALES, RITAFACILITY TYPE:
740
ADDRESS:44124 WESTRIDGE DRIVETELEPHONE:
(661) 289-0288
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 6DATE:
11/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Micaela OrozcoTIME COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Case Management - Deficiencies visit. LPA was greeted by staff Micaela Orozco. LPA requested staff contact administrator via telephone. The administrator Rita Morales informed LPA she would not be able to meet LPA at the facility. LPA explained the purpose of the visit. LPA reviewed the facility's Plan of Operation, facility's Plan of Operation did not have a plan that address the needs of residents with Dementia. Administrator designated staff Micaela Orozco to sign this report. This report is being generated to address the deficiency observed.

During the annual inspection on 10/16/2023 LPA reviewed resident files. While reviewing residents physician's reports and hospice documents LPA observed that two (2) out of the six (6) residents have a diagnosis of dementia, however licensee does not have an approved Plan of Operation that address the needs of residents with dementia. While speaking with administrator on 11/27/2023 LPA was informed that the facility has admitted residents who have a dementia diagnoses in the past. A brief discussion was held with the administrator regarding the requirements of admitting and retaining residents who have a diagnosis of dementia. According to the administrator, Licensee has been in business for a long time and has not run into this situation and no issues were brought up to the Licensee during the application process for the license. According to administrator the licensee will work on the program and send it to LPA in the next 24 hours.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited: (Refer to LIC 809-D) Exit Interview Conducted Copy of Appeal Rights and Report provided.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023
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 11/27/2023 11:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: CASA AMORE
FACILITY NUMBER: 197609345

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2023
Section Cited
CCR
87705(b)

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(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia...
This requirement is not met as evidenced by:
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Licensee will create and submit a Dementia Care plan for approval to CCL by POC due date.
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Based on interview and record review, the licensee did not comply with the section cited above in not providing CCL with a Plan of Operation that address the care needs of residents with dementia while currently providing services to residents with dementia which poses a potential health, safety or personal rights risk to persons in care.
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023
LIC809 (FAS) - (06/04)
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