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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005378
Report Date: 04/04/2022
Date Signed: 04/05/2022 01:10:12 PM

Document Has Been Signed on 04/05/2022 01:10 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:
306005378
ADMINISTRATOR:JENNIFER CARPENTERFACILITY TYPE:
772
ADDRESS:2534 SOUTH DEEGAN DRIVETELEPHONE:
(714) 375-1110
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY: 6CENSUS: 4DATE:
04/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Emerson GroomTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility for the purpose of conducting a Required - 1 Year inspection, with an emphasis on Infection Control due to the COVID-19 pandemic. LPA Martinez was granted entry into the facility by Behavioral Health Technician (BHT) Minli Flynn. Clinical Care Supervisor Emerson Groom arrived shortly after and reason for the visit was explained. BHT Flynn confirmed there are currently no cases or exposures of COVID-19 within the facility.

Currently there are 4 Clients living at the facility. There is no screening station at the entrance of the facility. There is a sign-in procedure in place and hand sanitizer for use that is kept in the medication room on the second floor. LPA was screened. LPA observed staff were wearing face masks. LPA conducted a tour of the facility and made observations pertaining to the facility's Infection Control measures. LPA did not observe the required Department posting on COVID-19 precautions at entrance of facility and/or throughout the facility. LPA toured client rooms, all rooms were within regulations. Restrooms observed contained hand washing soap, toilet paper and paper towels. The proper hand washing signs were posted in the restrooms. Facility has operating smoke and carbon monoxide detectors. Facility's Fire Extinguisher was charged. The facility was equipped with sufficient hand hygiene supplies, cleaning and disinfecting provisions. Personal Protective Equipment (PPE) supply is available. The facility monitors the Clients regularly for any COVID-19 symptoms/change of condition and documents. Facility has required Emergency Disaster Plan posted, and medication is stored in a Medication Room on the second floor.

Based on observations made during today’s inspection, no deficiencies are being cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with facility Representative and a copy will be emailed.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2022
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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