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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609839
Report Date: 07/26/2024
Date Signed: 07/26/2024 03:55:43 PM

Document Has Been Signed on 07/26/2024 03:55 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/
DIRECTOR:		TORTORICI, MARGARITAFACILITY TYPE:
740
ADDRESS:1715 LAKE WAYTELEPHONE:
(661) 522-3259
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 6CENSUS: 4DATE:
07/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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LPA Spaeth conducted an unannounced visit regarding Complaint #31-AS-20230801095955. LPA Spaeth reviewed resident files and discovered a new resident's file was not available. LPA Spaeth to a staff member who stated the resident (R2) moved in two days ago but the facility has not received the signed documentation from R2's family member. Also, LPA requested to review a previous resident's file (R1). Upon reviewing the file, LPA observed documents were missing from the file. LPA confirmed with the staff member the documents had not been obtained by the staff.

Based upon LPA's observations, and pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D).
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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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Document Has Been Signed on 07/26/2024 03:55 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 07/26/2024 at 01:04 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: 07/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2024
Section Cited
CCR
87506(a)

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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility…readily available to facility staff & to licensing agency staff. As evidenced by:
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The facility staff will obtain all the resident documents & will be obtained from the family. A copy of R2's documents will be faxed or emailed to LPA Spaeth.
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Based upon LPA review of the residents' files, LPA observed the documents for resident #2 (R2) were not available. The staff member stated R2 moved into the facility two days ago and staff are awaiting the signed documents from the family.
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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: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


LIC809 (FAS) - (06/04)
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