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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609839
Report Date: 06/24/2022
Date Signed: 06/24/2022 08:39:13 PM

Document Has Been Signed on 06/24/2022 08:39 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CASA AMORE WESTFACILITY NUMBER:
197609839
ADMINISTRATOR:TORTORICI, MARGARITAFACILITY TYPE:
740
ADDRESS:1715 LAKE WAYTELEPHONE:
(661) 522-3259
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 6CENSUS: 6DATE:
06/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lilia GaitanTIME COMPLETED:
04:45 PM
NARRATIVE
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LPA Spaeth conducted an unannounced visit to the facility and was greeted by caregiver. LPA observed caregiver was wearing a mask. Upon entering the facvility, LPA observed a resident was in the living room. LPA’s temperature was recorded and LPA also answered the COVID questions. LPA observed the sign in station which contained thermometer, hand sanitizer, and sign in sheet with COVID questions.

Living Room Area - LPA observed comfortable seating in the living room.

Dining Room/Kitchen Area - LPA observed two residents watching television in the dining room. LPA observed the sink area contained wash your hands sign, hand soap, and paper towels. A locked kitchen cabinet contained the knives and resident medications. LPA observed the refrigerator contained a five-day supply of fresh fruits and vegetables, eggs, and other dairy products. The freezer contained frozen meats and vegetables. The pantry was well-stocked with a seven-day supply of canned goods and other dry good items. LPA observed an adequate supply of PPE in a kitchen cabinet.

Hallway area - LPA observed a linen closet which contained clean linens, an adequate supply of PPE items, and diapers.

Residents' Rooms- There are five resident rooms. Each room contained bed, linens, chest of drawer, closet, night lamp, night stand and a chair. Each room was neat and clean.

Garage Area - LPA observed the washer, dryer, and cleaning supplies were locked in the garage.



Bathrooms - There are two bathrooms and a shower room in the facility. The bathrooms contained wash your hands sign, hand soap, paper towels, non-skid mat, and a trash can.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CASA AMORE WEST
FACILITY NUMBER: 197609839
VISIT DATE: 06/24/2022
NARRATIVE
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Backyard area -LPA observed a shaded area in the backyard which contained comfortable seating. The side gate was not locked that leads from the backyard to the front yard. LPA observed gardening tools on the west side of the backyard. LPA explained to caregiver that all gardening tools must be locked in the garage.

Under Title 22 General Regulations, the following citation was issued and recorded on LIC 809D.

Exit interview was conducted, appeal rights discussed and LPA gave a copy of the report during the visit.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/24/2022 08:39 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 06/24/2022 at 04:04 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA AMORE WEST
FACILITY NUMBER: 197609839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2022
Section Cited

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87705 Care of Persons with Dementia - (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s. This requirement is not met as evidenced by:.
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LPA Spaeth observed gardening tools such as two shovels, and two three prong gardening tools were not locked in a safe place which is an immediate health and safety risk to residents 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:Cassandra Harris
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022


LIC809 (FAS) - (06/04)
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