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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609839
Report Date: 08/07/2023
Date Signed: 08/07/2023 12:47:11 PM

Document Has Been Signed on 08/07/2023 12:47 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 WESTFACILITY NUMBER:
197609839
ADMINISTRATOR:TORTORICI, MARGARITAFACILITY TYPE:
740
ADDRESS:1715 LAKE WAYTELEPHONE:
(661) 522-3259
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 6CENSUS: 5DATE:
08/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Alma BustosTIME COMPLETED:
12:30 PM
NARRATIVE
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LPA Spaeth conducted an unannounced visit regarding Complaint 31-AS-20230801095955 and confirmed there are five residents living within.

LPA reviewed residents' records at 10:40 am until 11:15 am. LPA observed the residents' records were incomplete.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D).

Exit interview conducted, Appeal Rights discussed, and a copy of the report was issues to Administrator.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023
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 08/07/2023 12:47 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 08/07/2023 at 12:24 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: 08/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/14/2023
Section Cited
CCR
87506(d)

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87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit and copy upon demand…..
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Administrator will fax copies of R1, R3, R4 and R5 records to the attention of LPA Melissa Spaeth.
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LPA observed R3, R4 and R5 resident files were not available for review.
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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:Troy Agard
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2023


LIC809 (FAS) - (06/04)
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