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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700208
Report Date: 11/22/2023
Date Signed: 11/22/2023 04:33:55 PM


Document Has Been Signed on 11/22/2023 04:33 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:AMORUSO CARE HOMEFACILITY NUMBER:
342700208
ADMINISTRATOR:CHIRA, TITIANAFACILITY TYPE:
740
ADDRESS:8967 AMORUSO AVENUETELEPHONE:
(916) 475-7261
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
11/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Titiana Chira, AdministratorTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 11/22/23 and met with Administrator, Titiana Chira, to conduct an inspection.

During inspection, LPA reviewed an eviction notice issued to resident (R1). LPA observed that eviction notice was not in compliance with Health and Safety Code §1569.683. Eviction notice also stated that R1 "would need to agree to taking...medication," as well as other requests, and also states that "if you do not agree...the room must be vacated," which is a violation of R1's personal rights.

Due to the following information above, per California Code of Regulations, Title 22, Division 6, Chapter 8, and the Health and Safety Code, deficiencies are being cited on the attached 809-D page.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. The Administrator’s signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023
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 11/22/2023 04:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: AMORUSO CARE HOME
FACILITY NUMBER: 342700208

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2023
Section Cited
CCR
87468.1

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature (...). This requirement is not met as evidenced by:
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Facility will complete a statement of understanding regarding regulation 87468.1 and submit to LPA by POC due date of 12/1/2023.
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Based on records reviewed, the facility did not ensure that residents rights weren't violated when issuing an eviction notice, which poses a potential health, safety, and personal rights risk to the residents in care.
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Type B
12/01/2023
Section Cited
HSC1569.683(a)

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§1569.683 Eviction notices; reasons for eviction contents; service (a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident shall set forth in the notice to quit the reasons relied upon for the eviction, with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement is not met as evidenced by:
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Facility will issue a different notice that complies with Title 22 regulations and Health and Safety Code. Facility will also complete a statement of understanding regarding §1569.683 and submit to LPA by POC due date of 12/1/2023.
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Based on records reviewed, the facility issued an eviction notice to R1 that did not comply with Health and Safety Code, which poses a potential health, safety, and personal rights risk to the residents in care.
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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2