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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005248
Report Date: 12/20/2024
Date Signed: 12/20/2024 11:35:29 AM

Document Has Been Signed on 12/20/2024 11:35 AM - 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/
DIRECTOR:		MICHAEL YAMASHIROFACILITY TYPE:
772
ADDRESS:3044 GRANT AVENUETELEPHONE:
(714) 375-1110
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 4DATE:
12/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:58 AM
MET WITH:Ben Smith - Compliance Director TIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a required annual. LPA was greeted and granted entry into the facility by Yamilet Pineda, Behavioral Technician 1 and explained the reason for the visit. Ben Smith, Compliance Director arrived shortly after.

At 8:25AM LPA Mendivil toured the facility with LVN Wendy Gardner. LPA observed a 5 bedroom, 2 bathroom single story home with a detached garage. LPA toured all client's rooms and all the rooms had the required items including: bed, ample closet space, ample lighting and a chair. LPA Mendivil observed the garage is utilized as an activity/group room. LPA observed 3 locked cabinets in the garage that contained cleaning supplies and gardening tools. LPA Mendivil observed a locked laundry room. LPA Mendivil tested the hot water in two (2) bathrooms. The hot water temperature was recorded at: 111.6 degrees Fahrenheit and master bath at 117.6 degrees Fahrenheit. LPA Mendivil observed carbon monoxide detectors and smoke detectors throughout the facility, testing conducted and all detectors were operational.

LPA Mendivil observed secured and locked medication cabinet in locked medication room. LPA Mendivil observed that the clients medications were labeled. LPA Mendivil reviewed clients and staff records and files which contained the required documents.

Based on the observations made during this annual inspection conducted per Title 22 of the California Code of Regulations, no citations were issued. An exit interview was conducted with Compliance Director Ben Smith and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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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