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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005378
Report Date: 02/24/2023
Date Signed: 02/24/2023 01:35:26 PM

Document Has Been Signed on 02/24/2023 01:35 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
ORANGE & INLAND A/SC, 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: 5DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Emerson Groom, Clinical Care SupervisorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by Emerson Groom, Clinical Care Supervisor and LPA explained the nature of the visit.

LPA Martinez accompanied by Clinical Care Supervisor began the tour of the facility. There are five clients in care and no active covid cases in the facility. Client arrived shortly from being out in the community. Upon entry to the facility there is a sign-in procedure in place with temperature checks and covid testing as needed. LPA observed staff to be wearing face mask. LPA observed required department postings and covid precautionary posting in the facility. Facility has a Mitigation Plan on file with CCLD. There is a minimum of one week of non-perishables and two days of perishables foods available. Facility has an emergency food and water supply. The facility is equipped with sufficient hygiene, cleaning, and disinfecting supplies. Personal protective equipment (PPE) supply is available. The facility monitors the Clients regularly for any COVID-19 symptoms/change of condition and documents. All bathrooms observed to have a supply of soap, toilet paper and paper towels. LPA observed bathrooms to have hand washing signs posted. LPA toured the client’s bedrooms, all bedrooms observed to have all required components. Facility has required Emergency Disaster Plan posted. Facility has a secure locked location for medication in medication room which is inaccessible to clients in care. LPA observed the outside to the facility and observed several seating areas for clients use.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the Administrator and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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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