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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005925
Report Date: 04/05/2023
Date Signed: 04/05/2023 01:37:55 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/06/2023 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230306130632
FACILITY NAME:D'AMORE HEALTHCARE - CHEYENNEFACILITY NUMBER:
306005925
ADMINISTRATOR:SMITH, BENJAMINFACILITY TYPE:
772
ADDRESS:1055 CHEYENNE STREETTELEPHONE:
(714) 375-1110
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 3DATE:
04/05/2023
UNANNOUNCEDTIME BEGAN:
12:17 PM
MET WITH:Michael Yamashiro - Operations ManagerTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff are not providing adequate supervision to residents in care
Facility does not have enough staff to meet the needs of residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Patricia Velazquez conducted a subsequent complaint visit to deliver the findings of the investigation into the above allegations. LPA Velazquez was allowed entry into the facility and initially met with Behavioral Health Technician (BHT) Angella Galvan and explained the purpose of the visit. Operations Manager Michael Yamashiro arrived later to assist LPA with the visit.

On today's visit LPA Velazquez conducted interviews with clients. During the course of the investigation the following was revealed: LPA Velazquez conducted interviews with clients and staff. LPA Velazquez also reviewed and obtained copies of facility, client, and staff records. The records reviewed included Client (C) #1's Face Sheet, History and Physical Evaluation, Initial Psychiatric Evaluation, and Mental Health BioPsychosocial Assessment, Employee Work Schedules dated from January 29 - April 1, 2023, and Time Card Reports dated February 1 - March 31, 2023. Nine of nine individuals interviewed could not corroborate the above allegations. Seven of seven individuals interviewed felt there was sufficient staff present at all times to meet their needs.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20230306130632
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 - CHEYENNE
FACILITY NUMBER: 306005925
VISIT DATE: 04/05/2023
NARRATIVE
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Throughout the investigation LPA Velazquez observed several staff at the facility which included Behavioral Health Technicians, Licensed Vocational Nurses, Group Facilitators, Therapists, and an Operations Manager.

Based on the observations made by LPA Patricia Velazquez, interviews which were conducted and the records that were reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the following allegations: Staff are not providing adequate supervision to residents in care and Facility does not have enough staff to meet the needs of residents in care are deemed UNSUBSTANTIATED.

An exit interview was conducted with Operations Manager Michael Yamashiro and a copy of this report along with the LIC 811 was provided at the time of this visit. Due to technical issues LPA Velazquez was not able to print the report at the time of the visit. Operations Manager Yamashiro agreed to receive the report via email.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2