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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200624
Report Date: 09/22/2023
Date Signed: 09/22/2023 06:59:29 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/12/2022 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221012143303
FACILITY NAME:CASA AMORE CARE HOME INCFACILITY NUMBER:
079200624
ADMINISTRATOR:CAMACLANG, ALBERTINAFACILITY TYPE:
740
ADDRESS:2203 TICE VALLEY BLVDTELEPHONE:
(925) 705-7931
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 6DATE:
09/22/2023
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Licensee Albertina "Tina" CamaclangTIME COMPLETED:
07:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not assist resident with incontinence needs.
Facility is not obtaining or distributing medication to resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/22/2023 at 04:15 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to complete this investigation. Upon entering facility, LPA stated purpose of visit to staff member Evelyn Gordon. The Licensee arrived at approximately 4:30 PM.

Over the course of the inspection, the LPA interviewed 3 residents, 3 staff members, reviewed records (including the resident roster, physician reports, care plans, MAR, centrally stored medication records, and medication lists), and inspected the facility inside and outside.

Staff do not assist resident with incontinence needs.
Based on data collected from interviews with Residents R1 and R2, staff were not assisting residents with incontinent needs in an adequate or a timely fashion.

(Continued on 9099-C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/12/2022 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221012143303

FACILITY NAME:CASA AMORE CARE HOME INCFACILITY NUMBER:
079200624
ADMINISTRATOR:CAMACLANG, ALBERTINAFACILITY TYPE:
740
ADDRESS:2203 TICE VALLEY BLVDTELEPHONE:
(925) 705-7931
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 6DATE:
09/22/2023
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Licensee Albertina "Tina" CamaclangTIME COMPLETED:
07:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility providing inadequate meal services.
Facility is not clean.
Financial abuse.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/22/2023 at 04:15 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to complete this investigation. Upon entering facility, LPA stated purpose of visit to staff member Evelyn Gordon. The Licensee arrived at approximately 4:30 PM.

Over the course of the inspection, the LPA interviewed 3 residents, 3 staff members, reviewed records (including the resident roster, physician reports, care plans, MAR, centrally stored medication records, and medication lists), and inspected the facility inside and outside.

Facility providing inadequate meal services.
Based on data collected from interviews with Residents R1, R2, and R3, staff were and are currently providing adequate meal services.

(Continued on 9099-C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
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 7
Control Number 15-AS-20221012143303
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CASA AMORE CARE HOME INC
FACILITY NUMBER: 079200624
VISIT DATE: 09/22/2023
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
26
27
28
29
30
31
32
(...Continued from LIC9099)

Facility is not clean.
Based on data collected from an inspection of the facility inside and outside by the LPA, the facility was and is currently clean.

Financial abuse.
Based on data collected from interviews with Residents R1 and R2, and a review of the records, staff was not financially abusing residents.

Based on the data collected, although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with Licensee and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/12/2022 and conducted by Evaluator James Sampair
COMPLAINT CONTROL NUMBER: 15-AS-20221012143303

FACILITY NAME:CASA AMORE CARE HOME INCFACILITY NUMBER:
079200624
ADMINISTRATOR:CAMACLANG, ALBERTINAFACILITY TYPE:
740
ADDRESS:2203 TICE VALLEY BLVDTELEPHONE:
(925) 705-7931
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 6DATE:
09/22/2023
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Licensee Albertina "Tina" CamaclangTIME COMPLETED:
07:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is not fingerprint cleared.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/22/2023 at 04:15 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to complete this investigation. Upon entering facility, LPA stated purpose of visit to staff member Evelyn Gordon. The Licensee arrived at approximately 4:30 PM.

Over the course of the inspection, the LPA interviewed 3 residents, 3 staff members, reviewed records (including the resident roster, physician reports, care plans, MAR, centrally stored medication records, and medication lists), and inspected the facility inside and outside.

Staff is not fingerprint cleared.
Based on a review of the records, the staff present during inspections were fingerprint cleared.

(Continued on 9099-C...)
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 15-AS-20221012143303
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CASA AMORE CARE HOME INC
FACILITY NUMBER: 079200624
VISIT DATE: 09/22/2023
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
26
27
28
29
30
31
32
(...Continued from LIC9099)

Based on the data collected, the allegation is false, could not have happened, and/or is without a reasonable basis, therefore, the allegations are UNFOUNDED.

Exit interview conducted with Licensee and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 15-AS-20221012143303
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CASA AMORE CARE HOME INC
FACILITY NUMBER: 079200624
VISIT DATE: 09/22/2023
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
26
27
28
29
30
31
32
(...Continued from LIC9099)

Facility is not obtaining or distributing medication to resident.
Based on data collected from interviews with Residents R1 and R2, and a review of the records, staff was not obtaining or distributing medication to residents adequately and/or in a timely fashion.

Based on the data collected, the preponderance of evidence standard has been met; therefore, the above allegations have been found to be SUBSTANTIATED.

2 Type-B deficiencies have been cited per Title 22 California Code of Regulations (for details, refer to LIC9099-D). Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted with Licensee and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20221012143303
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CASA AMORE CARE HOME INC
FACILITY NUMBER: 079200624
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2023
Section Cited
CCR
87465(a)(5)
1
2
3
4
5
6
7
87465 INCIDENTAL MEDICAL AND DENTAL CARE SERVICES: (a) ... provide for assistance in obtaining ... care by... (5) ... assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee corrected deficiency.
8
9
10
11
12
13
14
Residents R1 and R2 stated, and their records supported their statements, that medications were not ordered and were not dispensed to them in a timely fashion.
8
9
10
11
12
13
14
Type B
09/29/2023
Section Cited
CCR
87625(b)(3)
1
2
3
4
5
6
7
87625 MANAGED INCONTINENCE: (b) ... the licensee shall be responsible for ... (3) Ensuring that incontinent residents are kept clean and dry ...

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee corrected deficiency.
8
9
10
11
12
13
14
Residents R1 and R2 stated, and their records supported their statements, that their adult diapers were not kept dry and clean in a timely fashion.
8
9
10
11
12
13
14
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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7