306005543-5-25-2023-22-AS-RMAZ-CS6PJZ-20230525112223

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005543
Report Date: 05/25/2023
Date Signed: 05/25/2023 03:29:53 PM

Document Has Been Signed on 05/25/2023 03:29 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 HEALTHCARE - S RENE		FACILITY NUMBER:	306005543
ADMINISTRATOR:	JOHN EMMA		FACILITY TYPE:	772
ADDRESS:	2902 S RENE DR		TELEPHONE:	(714) 375-1110
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92704
CAPACITY: 6		CENSUS: 4	DATE:	05/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Michael Yamashiro		TIME COMPLETED:	11:40 AM

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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for completing a required annual inspection. LPA arrived at facility was greeted and granted entry by staff. LPA met with Michael Yamashiro, Operations Manager the nature of the visit.

Four clients currently reside at this location and clients were at in the community at the time of visit. LPA accompanied by Operations Manager began the tour of the inside and outside of the facility, facility is a two-story home. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. LPA toured the kitchen and food storage areas. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food stored in garage refrigerators and pantry. The facility is maintained at a comfortable temperature. LPA inspected that medication are centrally stored in a safe locked storage closet in med room. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care. LPA measured the hot water temperature which measured 106.8 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored and locked in storage cabinets. The facility has an available clean supply of linens. LPA inspected client’s bedrooms which has sufficient lighting to ensure the safety and comfort. Storage space is provided for clients in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there is several seating areas for client’s enjoyment. LPA observed a fire extinguisher with service date of March 17, 2023, mounted on the walls throughout the facility. Fire drills conducted quarterly, and LPA verified last fire drill was conducted on January 16 & 19, 2023. LPA began review of records. Records are kept electronically and were made available to LPA. LPA reviewed two clients’ records. All the required documentation was present and current

Continued on LIC809-C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HEALTHCARE - S RENE	FACILITY NUMBER: 306005543
	VISIT DATE: 05/25/2023

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in client’s files reviewed. LPA reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate. LPA as a reminder provided annual fee dues information.

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

This report was reviewed with facility representative and a copy of this report was provided and left at facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC809 (FAS) - (06/04)

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