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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005543
Report Date: 06/07/2022
Date Signed: 06/07/2022 03:19:36 PM

Document Has Been Signed on 06/07/2022 03:19 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 HEALTHCARE - S RENEFACILITY NUMBER:
306005543
ADMINISTRATOR:JOHN EMMAFACILITY TYPE:
772
ADDRESS:2902 S RENE DRTELEPHONE:
(714) 375-1110
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY: 6CENSUS: 3DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Alyssa VenegasTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted by staff Alyssa Venegas and granted entry into the facility. LPA Gutierrez discussed the purpose of the inspection. During the inspection LPA Gutierrez and staff Venegas conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage observed the following:

This is a two-story house with six bedrooms, and three bathrooms, with one bedroom being used as an office for staff. Residents were observed in the dining area and in individual therapeutic sessions. A 2-day supply of perishable and a 7-day supply of non-perishable food was observed during today’s visit. LPA observed the facility has a 30-day supply of PPE on hand. LPA observed hallways and walkways were free of obstruction.

LPA reviewed and confirmed facility policies and practices regarding resident screening; a Technical Advisory was given on this date, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, infection control training; a Technical Advisory was given on this date, PPE, staffing and staffing shortages.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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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