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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005248
Report Date: 12/17/2021
Date Signed: 12/29/2021 05:46:01 PM

Document Has Been Signed on 12/29/2021 05:46 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:D'AMORE HEALTHCAREFACILITY NUMBER:
306005248
ADMINISTRATOR:MICHAEL YAMASHIROFACILITY TYPE:
772
ADDRESS:3044 GRANT AVENUETELEPHONE:
(949) 892-3020
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 3DATE:
12/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Michael Yamashiro, AdministratorTIME COMPLETED:
01:40 PM
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D'AmLicensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of
conducting required 1 - Year Inspection. LPA was greeted and granted entry into the facility by Administrator .
There are three residents residing in the facility and no active COVID-19 cases. , resident and staff are vaccinated. LPA observed three residents on site. All residents appeared clean and well
taken care of.

LPA Frank toured the facility. All to the Social Rehabilitation facility, which is documented as Social Rehabilitation Residential Program licensed for treatment program for 6 ambulatory individuals. During todays visit LPA met with Michael Yamashiro, Administrator, explained the purpose of the this crisis residential program with an average stay of 30 to 45 days
LPA conducted a general overall inspection, which included, but was not limited to the following:
Clinical Supervisor provided LPA with a tour inside and out of the facility. The following was observed: capacity; facility temperature 119.1 degrees; water temperature tested, indoor passageways; diet quality and quantity necessary to meet resident’s needs; nonperishable foods and perishable supply; staff, sufficient supplies linens. Fire alarms tested, carbon monoxide detector observed.Staff have received required training and criminal record clearances. LPA also determined there were no excluded personnel employed by the facility. First aid kit was available. Mental health intake assessments are prepared as required by Health and Safety Code Section 1562.6(a). Licensee to submit a new LIC 500, Designation of Responsibility LIC 308 and LIC 610 within 10 days. LPA observed . Facility has back-up emergency food and water supply as well as PPE supplies. Facility has completed the LIC 808 Mitigation Plan. The facility is still conducting COVID-19 testing as required by the latest guidance.

No citations noted during today's visit. Exit interview conducted and a copy of this report was provided
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2021
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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