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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005378
Report Date: 04/30/2024
Date Signed: 04/30/2024 10:48:10 AM

Document Has Been Signed on 04/30/2024 10:48 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:D'AMORE HEALTHCAREFACILITY NUMBER:
306005378
ADMINISTRATOR/
DIRECTOR:		JENNIFER CARPENTERFACILITY TYPE:
772
ADDRESS:2534 SOUTH DEEGAN DRIVETELEPHONE:
(714) 375-1110
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY: 6CENSUS: 4DATE:
04/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Sumeeta Rai-Behavioral Health Technician, Elissa Venegas-Operations ManagerTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Behavioral Health Technician (BHT) Sumeeta Rai. Operation Manager (OM) Elissa Venegas arrived shortly after.

For today’s visit, LPA observed a total of four clients in care and two staff members on duty.

LPA Ramirez toured the interior and exterior portions of the facility with OM Venegas. The facility is a two story structure and is licensed for six ambulatory clients. There are a total of five bedrooms, of which three are private client bedrooms, and the remaining two are being used as staff office. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detectors were tested and operational. There are a total of three restrooms. Restrooms were observed to be in good repair, to have a supply of soap, toilet paper and paper towels. LPA observed bathrooms to have hand washing signs posted. Water temperature tested between 111.7-112.3 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to clients in care. Fire extinguishers were charged, and one was located by the kitchen, one in the garage and one by the clients' bedroom hallway.

CONTINUED ON LIC809-C...

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: D'AMORE HEALTHCARE
FACILITY NUMBER: 306005378
VISIT DATE: 04/30/2024
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LPA Ramirez observed the emergency disaster and evacuation plan. Facility had back-up emergency food and water supply. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to clients in care.

For the exterior portion, LPA Ramirez observed a shaded patio area with furniture, and the grounds were free of any hazards. There is 1 gate in the backyard, which is self-closing and self-latching. No bodies of water were observed.

LPA reviewed four client files and two staff files. LPA interviewed clients and staff present.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with OM Venegas.

A copy of this report was provided at the time of exit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC809 (FAS) - (06/04)
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