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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005925
Report Date: 06/14/2022
Date Signed: 06/14/2022 12:13:57 PM

Document Has Been Signed on 06/14/2022 12:13 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 - CHEYENNEFACILITY NUMBER:
306005925
ADMINISTRATOR:SMITH, BENJAMINFACILITY TYPE:
772
ADDRESS:1055 CHEYENNE STREETTELEPHONE:
(714) 375-1110
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 5DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Ramen CarpenterTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced annual inspection focusing primarily on the Infection Control. LPA was greeted and granted entry by Behavioral Health Tech (BHT) Grecia Taylor. LPA stated the purpose of the visit and entered the facility at 10:16 am after completing the Coronavirus 2019 (COVID-19) screening procedure. As of today, there are no active COVID-19 cases in the facility. LPA observed that facility screened and documented temperatures for visitors in the entryway. The required COVID-19 precautionary signs were posted on the front door and the entryway.

Around 10:25 am, LPA and BHT Taylor toured the interior and exterior portions of the facility. Supervisor Ramen Carpenter assisted the tour around 10:40 am. The facility is a single level structure and licensed for six ambulatory clients. As of today, there were five clients in the facility. LPA observed four clients at the dining table and one client resting in the bedroom. Facility appeared clean and sanitary in all observed areas. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxides tested operational. Restrooms observed to be in good repair; and provided with a grab bar and a non-skid floor mat. Facility had the required hand washing signs posted in all the restrooms and provided hand soaps and paper towels. Hot water measured at 109.5 degrees Fahrenheit in Restroom #1 and 110.8 degrees Fahrenheit in Restroom #2. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to the clients in care. The three fire extinguishers were mounted of which one was not charged. In addition, the three fire extinguishers were last serviced on 3/8/2021 and exceeded their annual inspection date. The fire extinguishers were purchased from Home Depot and were replaced during the visit. For the exterior portion, the facility had an outdoor visitation area with a patio furniture under ample shading, and grounds were free of tripping hazards. The side gates were self-closing and self-latching. LPA observed the incorrect LIC610 Emergency Disaster for Child Care Centers dated 2/19/2021 was used instead of the LIC610D Emergency Disaster Plan for Social Rehabilitation Facilities.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/14/2022
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Facility had sufficient PPE, emergency food, and water supply. Facility had a secured medication area in the Medication Room along with the First Aid Kit which had all the required components except a manual.

LPA consulted the following: Facility will update and implement the LIC610D Emergency Disaster for Social Rehabilitation Facilities and to purchase a First Aid Kit Manual.

LPA Cho reviewed the approved COVID 19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit, and the licensee will follow-up with the corrections. An exit interview was conducted with Supervisor Ramen Carpenter, and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC809 (FAS) - (06/04)
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