197609839-7-20-2024-31-AS-JGTN-D7CQT8-20240720122643

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609839
Report Date: 07/20/2024
Date Signed: 07/20/2024 12:28:24 PM

Document Has Been Signed on 07/20/2024 12:28 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CASA AMORE WEST		FACILITY NUMBER:	197609839
ADMINISTRATOR:	TORTORICI, MARGARITA		FACILITY TYPE:	740
ADDRESS:	1715 LAKE WAY		TELEPHONE:	(661) 522-3259
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	6	CENSUS: 3	DATE:	07/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Alma Bustos - Staff		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Gary Tan conducted an unannounced visit at this facility for a One (1) year Required visit. LPA met with staff Alma Bustos who called the administrator Rita Morales and explained the purpose of the visit. Ms. Morales designated Ms. Bustos to sign the report. A tour of the physical plant was conducted at 9:12 AM. The facility has four (4) bedrooms and two (2) bathrooms and one (1) shower room, currently occupying three (3) residents on two (2) private rooms and two (2) private rooms. The facility fire cleared for six (6) non-ambulatory residents, one of which may be bedridden in Room #4. Hospice waiver for four (4) residents. There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation plan and Infection plan. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with the family room. The facility maintains a comfortable temperature at 75°F. The carbon monoxide and smoke detector are tested and observed to be operational. Smoke detectors are hardwired and interconnected. Fire extinguisher is located in the kitchen and observed to be full and last bought on 07/20/24. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water at the facility. (continued on LIC 809-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2024

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA AMORE WEST	FACILITY NUMBER: 197609839
	VISIT DATE: 07/20/2024

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(continued from 809-C)

The garage is attached to the house and currently being used as laundry area, PPE and frozen food storage. The garage was observed to be locked during visit. Laundry area is in the garage, laundry soap and other cleaning agents are kept in a locked cabinet in the garage.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies, pesticides and other toxins are stored in a locked cabinet in the garage and inaccessible to residents.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Clients have sufficient amounts of personal hygiene products on each bathroom which is provided by the licensee.

The bathrooms and shower room were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at a range of 116.9°F to 118.7°F. There is sufficient supply of clean linen available in stock at the cabinet.

Medications: LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. Complete first aid kit is readily available.

Client records: Client records are reviewed. One (1) out of three (3) residents file reviewed has no medical assessment on file.
Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated. Disaster drill was last conducted on 07/30/23. Required posting observed in facility (complaint hot line poster).

Citation issued. Appeal rights discussed and given. Exit interview conducted and copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/20/2024 12:28 PM - 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA AMORE WEST	FACILITY NUMBER: 197609839
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (record review, the licensee did not comply with the section cited above in 1 out of 3 resident records reviewed had no LIC 602 on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/30/2024
	Plan of Correction
1 2 3 4	Staff will inform the administrator to have R1 get a medical assessment and submit to CCL on or before the POC date

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above as there is no record of fire drill for the last three (3) months, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/30/2024
	Plan of Correction
1 2 3 4	Staff will inform the administrator to conduct fire/disaster drill and submit proof of the drill to CCL on or before the 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: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2024

LIC809 (FAS) - (06/04)

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