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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609839
Report Date: 11/26/2023
Date Signed: 11/26/2023 05:08:16 PM

Document Has Been Signed on 11/26/2023 05:08 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:
11/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Rosalva Arredondo TIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility 12:00 pm. LPA disclosed to staff the purpose of the visit. LPA Smith contacted the administrator at 12:20 pm. The administrator authorized staff Rosalva Arredondo to sign report.

LPA conducted a tour of the physical plant at approximately 12:25 pm to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common areas were observed for the ability to safely serve the needs residents. These included the living room, dining room and kitchen. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to have adequate seating for residents.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The
kitchen food supply was observed and sufficient for the six (6) residents currently residing there. Two (2) days of
perishable food observed. The freezer is stocked with meats and frozen vegetables. Resident medications, sharps, and (1) large first aid kit box stored in large cabinet in next to refrigerator. Medications and sharps observed to be locked and inaccessible to residents in care. Toxins are stored and locked in a locked storage cabinet in garage. There is one (1) fire extinguisher attached to wall in the garage and observed to be charged.

Laundry room is located in the garage. The appliances observed to be clean and functional.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 11/26/2023 05:08 PM - It Cannot Be Edited


Created By: Tihesha Smith On 11/26/2023 at 04:05 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: 11/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

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 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
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:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 11/26/2023 05:08 PM - It Cannot Be Edited


Created By: Tihesha Smith On 11/26/2023 at 04:05 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: 11/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) he licensee did not comply with the section cited above as several paint cans not locked in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
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The Licensee/Administrator will locked paint cabinets/or garage. POC due:11/27/23
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:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/26/2023 05:08 PM - It Cannot Be Edited


Created By: Tihesha Smith On 11/26/2023 at 04:05 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: 11/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)(12)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview) (record review)], the licensee did not comply with the section cited above the operation plan not available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
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The Licensee/Administrator will send plan of operation to LPA by Poc date.
Type B
Section Cited
CCR
87208(c)
Plan of Operation
(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based oninterview) (record review)], the licensee did not comply with the section cited above the dementia plan not available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
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The Licensee/Administrator will send plan of to LPA by Poc date.
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:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 11/26/2023 05:08 PM - It Cannot Be Edited


Created By: Tihesha Smith On 11/26/2023 at 04:05 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: 11/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 as faucet not working/broken at time of inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
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Licensee/Administrator will contact LPA and provide resolution/repair dates.
Type B
Section Cited
HSC
1569.695(a)(1)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) /(record review)], the licensee did not comply with the section cited above the plans not available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
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The Licensee/Administrator will send plan to LPA by Poc date.
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:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2023


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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: 11/26/2023
NARRATIVE
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(Cont. from 809)

The facility has a total of five (5) bedrooms and (2) bathrooms and one (1) shower only room. There is no staff room.

The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens in hall closet and in shower only room.

Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured for the two (2) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was between 127.0 and 129.8 -degrees Fahrenheit.

Backyard has the following: Covered patio with tables and chairs. Patio furniture observed to be in good repair.

Attached Garage: Used for PPEs and storage.

Smoke detectors/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards.

At approximately 1:30 pm, LPAs reviewed three (3) staff files. Staff files were incomplete/or missing signatures, one (1) or more records missing current First aid/CPR. Three (3) random resident files reviewed. Resident records missing dates and forms. Facility plans to include but not limited to the operation plan and dementia plan not available for review.

Deficiencies cited on 809-D
Exit Interview Conducted /Appeals/Copy of the Report given
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2023
LIC809 (FAS) - (06/04)
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