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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209123
Report Date: 10/08/2021
Date Signed: 10/08/2021 02:58:36 PM

Document Has Been Signed on 10/08/2021 02:58 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: 3DATE:
10/08/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrators Pacita Baltazar and Alex BabakhaniTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) M. Yang arrived unannounced for a Post Licensing -Infection Control Inspection. LPA met caregiver Amalia (Amy) Mallari. LPA introduced self, stated the purpose of the visit, and requested to meet with the Administrator. Upon entry staffs was observed not wearing facial covering. Administrators, Pacita Baltazar and Alex Babakhani was called and arrived shortly.

LPA conducted a complete tour of the facility with the Administrators. All three residents present during visit. LPA observed cough etiquette and social distancing posting. Facility was observed at a comfortable temperature, clean, and no passageway obstructions or fire hazards inside. Facility was free from ground obstructions and odor free. Common areas were observed to have adequate seating and lighting available.

Kitchen was toured and observed. Knives were observed kept locked and secure in the kitchen pantry. LPA observed a 2-day supply of perishable and 7-day supply of non-perishable food. Medications observed locked in two cabinets in the kitchen. A fire extinguisher was observed and had a service date of 07/25/2021. Cleaning supplies and chemicals observed to be locked in a closet in the laundry room. LPA observed an extra supply of bed linens and personal hygiene products. Bedrooms were observed furnished and lit. LPA observed hand washing signs by bathroom sinks. Hot water temperature ranged between 109.6 to 112 degrees F. Outside of facility toured. Exits were open and free of obstructions. LPA observed side gate to be self-latching. All resident’s file reviewed to have updated emergency contact information. LPA observed a 30 day PPE supplies. Resident’s MARS reviewed. Staff’s file was also reviewed with current 1st Aid/ CPR.

No deficiencies issued during this inspection.

Exit interview was conducted. Due to COVID-19 precautionary measures, a copy of this report will be provided via email and an electronic read receipt confirms receiving this email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2021
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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