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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209123
Report Date: 08/19/2022
Date Signed: 08/19/2022 10:32:20 AM

Document Has Been Signed on 08/19/2022 10:32 AM - 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: 4DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Administrator Alex Babakhani and Adminsitrator Pacita BaltazarTIME COMPLETED:
10:45 AM
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On 8/19/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Myrna Alonzo, Caregiver. Administrator Alex Babakhani and Administrator Pacita Baltazar was called and arrived shortly and conduct tour with LPA. Three residents were present during the inspection.

Upon entry facility staff was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Social distancing and cough etiquette postings observed.

Staff records were reviewed for good health and infection control training. All resident records reviewed to have updated emergency contact information. LPA observed 30-day PPE supplies.

Cleaning supplies were stored and locked in laundry closet. LPA observed fire extinguisher served date: 5/8/22. LPA observed four single occupant room to be adequately furnished and lit. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. Hand washing posting observed by bathroom sinks. Food supply was checked and appeared to be an adequate supply. LPA checked residents’ locked medications. The exterior tour was conducted. Side gate was self-closing and free of obstruction.

No deficiencies issued during this inspection.

Exit Interview conducted. LPA received copy of Lic 308, Lic 610E, Lic 309, Lic 500, Lic 9020, Administrator certificate, current liability insurance. A copy of this report was provided to Administrator.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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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