374604497-2-7-2022-08-AS-KRYN-CBF2YH-20220207164845

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604497
Report Date: 02/07/2022
Date Signed: 02/07/2022 04:50:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	AMPARO SENIOR CARE		FACILITY NUMBER:	374604497
ADMINISTRATOR:	CAPATI, ANNA		FACILITY TYPE:	740
ADDRESS:	1029 BOULDER PLACE		TELEPHONE:	(760) 576-5487
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY:	6	CENSUS: 5	DATE:	02/07/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Anna Capati		TIME COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Kristina Ryan conducted an announced Pre-Licensing inspection. LPA identified herself to Administrator, Anna Capati, and explained the purpose of the visit which was to evaluate Title 22 compliance for a Change of Ownership application. The facility plans to serve elderly residents, ages 60 and over. The Fire Clearance was granted on January 02, 2022. Facility is approved for 6 residents, 6 of whom can be non-ambulatory. Facility is approved for 1 bedridden resident. Facility has a Hospice Waiver for 6 residents. An inspection of the facility was conducted inside and out. A sample of resident rooms were observed. Bathrooms are equipped with toilets, and hand-washing and bathing facilities are sanitary and in operating condition. Water temperature was recorded at 110.7 to 118.6 Fahrenheit. Each room was set at a comfortable temperature. All lighting fixtures and facility windows were operable and in good condition. Outdoor and indoor passageways were free from obstructions. Fire extinguishers were affixed with current tags. Smoke and carbon monoxide detectors were present and operational. There were no pools or other bodies of water observed on the premises. Locked cabinets and storage areas were identified to store toxic substances, knives, and medication. Hazardous items were stored such that they were inaccessible to residents. Per Administrator Capati, no weapons or ammunition are or will be stored at the facility.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina Ryan	TELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: AMPARO SENIOR CARE	FACILITY NUMBER: 374604497
	VISIT DATE: 02/07/2022

NARRATIVE

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LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) with Ms.Capati. LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety.

LPA observed facility accommodations including food supplies, medication storage, first aid kit as well as toiletries and linens. Required CCLD postings were present. LPA reviewed a sampling of staff and resident records. Resident records that were reviewed included admissions agreements, physician's reports, and pre-placement appraisals. Staff records were reviewed for criminal background clearance, criminal record statement, and first aid/ CPR training. The administers Administrator Certification expires October 17, 2023. Component III was reviewed with administrator. The application will be sent to the Centralized Application Bureau for final review and approval.

An exit interview was conducted with Administrator, Anna Capati. A copy of this report, along with the Licensee Rights (9058 01/16) was emailed to Ms. Capati at the conclusion of the visit, an electronic response confirms the receipt of these documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina Ryan	TELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022

LIC809 (FAS) - (06/04)

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