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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201064
Report Date: 06/17/2021
Date Signed: 06/17/2021 04:19:42 PM

Document Has Been Signed on 06/17/2021 04:19 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:AMBER CARE HOMEFACILITY NUMBER:
079201064
ADMINISTRATOR:DEL ROSARIO, ANATOLIAFACILITY TYPE:
740
ADDRESS:3744 PINTAIL DR.TELEPHONE:
(925) 706-9922
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 6DATE:
06/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Anatol Del Rosario, AdministratorTIME COMPLETED:
02:00 PM
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On 6/17/2021 at 01:40pm, Licensing Program Analyst (LPA) L. Hall conducted a Component III Review, for the Pre-licensing Inspection which was conducted on this date.

LPA reviewed Component III with Administrator Anatol Del Rosario.

A license has not yet been granted to this facility. Licensure is subject to final review and approval by the Centralized Applications Unit. Licensee is not to accept residents until notified by Community Care Licensing that the license has been approved.

See LIC809 (Pre-licensing Inspection) Report dated 06/17/2021, for the Pre-licensing Inspection conducted in relation to this report.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2021
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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