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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005925
Report Date: 07/17/2023
Date Signed: 07/17/2023 11:52:09 AM

Document Has Been Signed on 07/17/2023 11:52 AM - 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: 3DATE:
07/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Michael YamashiroTIME COMPLETED:
12:05 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Michael Yamashiro and discussed the purpose of the inspection. Administrator (AD) Benjamin Smith was not present during the inspection.

LPA reviewed Infection Control requirements. At about 9:15AM, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure: facility is a 4-bedroom, 2-bathroom, one-story house with an attached garage that is being used for activities. There is a back yard with a patio cover for the clients. LPA observed 2 staff and 3 clients present at the facility. Client Bedrooms: the 4 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 109.5 degrees F in the common bathroom and 109 degrees F in the master bedroom bathroom. LPA inspected all rooms in the facility. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the storage closet. Toxins: observed locked in the garage. Medication closet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. LPA discussed the facility’s licensing fees with S1. At about 10:00AM, LPA reviewed 3 client files and 6 staff files, interviewed 3 clients and 2 staff, inspected medications for 3 clients, and inspected client property and property logs for 3 clients.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2023
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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Document Has Been Signed on 07/17/2023 11:52 AM - It Cannot Be Edited


Created By: Sean Haddad On 07/17/2023 at 11:43 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81065.5(a)(2)
Day Staff-Client Ratios
(2) Short Term Crisis Residential Programs shall have at least two direct care staff persons on duty, on the premises, any time clients are in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews, since licensure the facility's schedule has included periods of time during the day shifts when there is only one direct care staff present at the facility, which poses a potential health and safety risk to persons in care.
POC Due Date: 08/07/2023
Plan of Correction
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Licensee stated they will immediately start having two day shift direct care staff and will submit proof by way of completed work schedules to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023


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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: D'AMORE HEALTHCARE - CHEYENNE
FACILITY NUMBER: 306005925
VISIT DATE: 07/17/2023
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During the inspection, S1 stated that since licensure the facility's schedule has included periods of time during the day shifts when there is only one direct care staff present at the facility because there is one assigned direct care staff during the day shifts while additional staff cycle in and out of the facility. LPA reviewed the facility’s license which states it is a Short-Term Crisis Residential Program.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
LIC809 (FAS) - (06/04)
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