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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005925
Report Date: 03/07/2023
Date Signed: 03/07/2023 12:00:27 PM

Substantiated


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
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: 4DATE:
03/07/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Michael Yamashiro - Operations ManagerTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff do not report incidents involving residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced initial 10 day complaint visit to initiate the investigation into the above allegation. LPA Velazquez was allowed entry into the facility and met with Operations Manager (OM) Michael Yamashiro and explained the purpose of the visit.

On today's visit LPA Velazquez conducted interviews with clients and staff. LPA Velazquez also requested copies of facility and client records. During the course of the investigation the following was revealed: LPA Velazquez conducted interviews with clients and staff. During today's visit, OM Yamashiro confirmed with Chief Compliance Officer Benjamin Smith that an Incident Report had not been submitted to Licensing for the incident involving Client (C) #1 which occurred on February 26, 2023. Based on LPA's observations, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff do not report incidents involving residents in care is deemed SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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: 03/07/2023
NARRATIVE
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California Code of Regulations, Title 22, Division 6, Chapter 2 is being cited on the attached LIC 9099D page. LPA Velazquez printed and provided a copy of Title 22 Regulation Section 81061 Reporting Requirements to OM Michael Yamashiro who acknowledged receiving a copy of this regulation during this visit.

An exit interview was conducted with Operations Manager Michael Yamashiro and a copy of this report along with the Appeal Rights, LIC 811, and LIC 9098 were provided at the time of this visit.

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

DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2023
Section Cited
CCR
81061(b)(1)(E)
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Reporting Requirements. Upon the occurrence...of any of the events specified in Section 81061(b)(1) below, a report shall be made to the licensing agency within the agency's next working day...(1) Events reported shall include the following: (E):
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Licensee to ensure it meets Title 22 Regulation regarding Reporting Requirements and submit an Incident Report for C1 to LPA by POC due date.
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Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement is not met as evidenced by: based on record review & interview the Licensee did not report C1's incident to Licensing. This poses a potential risk to the health and safety of clients in care.
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Licensee to submit a written statement to LPA indicating how they intend to adhere to this regulation by POC due date.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4