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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209123
Report Date: 08/18/2021
Date Signed: 08/19/2021 05:10:25 PM

Document Has Been Signed on 08/19/2021 05:10 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:AMBER CARE HOMEFACILITY NUMBER:
107209123
ADMINISTRATOR:BABAKHANI,ARDALAN ALEXFACILITY TYPE:
740
ADDRESS:399 AMBER AVE.TELEPHONE:
(559) 392-0393
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 0DATE:
08/18/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Facility Staff, Pacita Baltazar and Administrator, Alex BabakhaniTIME COMPLETED:
11:55 AM
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On 08/18/2021, Licensing Program Analysts (LPAs) Walton and Yang conducted an announced Pre-licensing / Component III Inspection. LPAs introduced selves, stated the purpose of the visit and was allowed entry into the facility. LPAs met with Facility Staff (S1), Pacita Baltazar and Administrator (A1), Alex Babakhani.

The facility is a 5 bedroom and 2 bathroom home and fire clearance was granted for 6 Non-Ambulatory for a total capacity of 6. There are no residents present during this inspection.

LPAs toured the facility with A1 and S1. Facility was free from ground obstructions and odor free. Common areas were observed to have adequate seating and lighting available. Bedrooms were observed to have the required furnishing and are ready for occupancy. Hot water temperature ranged between 108.1 to 110.3 degrees F.

LPAs observed an extra supply of bed linens and personal hygiene products. Kitchen was toured and observed to have dishes, plates, and utensils. Knives will be kept locked and secure in the kitchen pantry. Medications will be locked in two cabinets in the kitchen. First aid kit was observed and contained all required items. Cleaning supplies and chemicals observed to be locked in a closet in the laundry room. A fire extinguisher was observed and had a service date of 07/25/2021. Smoke detectors and carbon monoxide were observed to be operational during this inspection.

Outside of facility toured. Exits were open and free of obstructions. LPAs observed side gate to be self-latching.

Component III was conducted during today's pre-licensing visit.

We have found that the applicant has met all pre-licensing requirements. LPAs will submit documentation to CAB in Sacramento for final review prior to license being issued.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2021
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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