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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005248
Report Date: 12/06/2022
Date Signed: 12/06/2022 01:57:14 PM

Document Has Been Signed on 12/06/2022 01:57 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:
(714) 375-1110
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 5DATE:
12/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Michael YamashiroTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at D'Amore Healthcare to conduct an unannounced Required 1 Year Inspection with an emphasis on Infection Control. At 12:48am, LPA Cho was greeted and granted entry by Behavioral Health Technician (BHT) Angella Galvan and Maintenance Kyle Emma. LPA completed the Coronavirus 2019 (COVID-19) screening procedure upon entry. There are no active COVID-19 cases as of today. LPA observed a digital thermometer by the entrance and the sign in sheet that was located in the office with the visitor's temperatures documented. LPA did not observe the required COVID-19 precautionary signs posted throughout the facility.

At 12:55pm, LPA conducted a tour of the physical plant with BHT Angella Galvan. Approximately 1:05pm, LPA met with Administrator (Admin) Michael Yamashiro who assisted with the tour. There are a total of five client bedrooms and two client bathrooms. LPA checked the client bedrooms. The client bedrooms had the required furnishings. The client bathrooms were checked. The toilets worked properly, showers were free of mold/mildew, bathrooms were adequately stocked with hand soaps and paper towels. Hand washing signs were observed in the bathrooms. The hot water temperature in the client bathrooms measured at 125.7 degrees Fahrenheit in Bathroom #1 and 127.9 degrees Fahrenheit in Bathroom #2 which exceeded the required range. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguishers were mounted, fully charged, and serviced on 06/20/2022. Smoke/carbon monoxide detectors were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the clients. LPA Cho toured the outside grounds. There was shading and sufficient seating for clients. The exit gates were self-closing and self-latching. Walkways around the facility were clear of hazards, and LPA observed sufficient supply of emergency food/water and PPEs.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102s) were issued during the visit. An exit interview was conducted with Administrator Michael Yamashiro, and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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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