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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209123
Report Date: 08/19/2024
Date Signed: 08/19/2024 04:40:25 PM

Document Has Been Signed on 08/19/2024 04:40 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:AMBER CARE HOMEFACILITY NUMBER:
107209123
ADMINISTRATOR/
DIRECTOR:		BABAKHANI,ARDALAN ALEXFACILITY TYPE:
740
ADDRESS:399 AMBER AVE.TELEPHONE:
(559) 940-7201
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 4DATE:
08/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Administrator: Ardalan Alex BbakahaniTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 08/19/24 Licensing Program Analysts (LPA) L. Xiong and J. Leffall arrived unannounced to conduct an Annual Inspection. LPAs introduced selves, stated the purpose of the visit, and was greeted by Administrator (A1) Alex Babakhani. LPAs were granted entry. 2 clients were present during inspection.

LPAs toured facility with A1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at 0 degrees F and refrigerator temperature was maintained at 37 degrees F. Cleaning chemicals were observed stored and locked under kitchen sink. Fire extinguisher was observed with a service date of: 04/11/24. Fire drill last completed on 08/7/24. Clients' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested 118.9 degrees F. in bathroom 1 and in bathroom 2. Outside of facility toured. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Medications were checked and observed kept locked in medication cart. Clients’ MARS was reviewed. Medication Fludrocortisone .1 MG tablets, Dosage Instructions: 1 tablet per day, daily. Instructions were written in Mars by staff and not by the Dr. or Pharmacy. Carbon monoxide and smoke detectors were tested and observed to be operational. All clients’ file reviewed to have all the required documents. A sample of staff files and all clients’ files were reviewed and observed to have all the required documents.

The following deficiencies were cited: Incidental Medical and Dental - Type A: 87465(c)(2) - Dr's direction states on prescription label for medication to be given one tablet daily and not as needed. LPA's observed hand written medication instructions by staff and not by Pharmacy or Dr.

Exit Interview conducted. The following documents requested to be updated and submitted to Fresno CCL by 08/31/24: Lic 308, Lic 500, Lic 610D, and Lic 9020. LPA received a copy of current Administrator certificate. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of these report.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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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Document Has Been Signed on 08/19/2024 04:40 PM - It Cannot Be Edited


Created By: Jacques Leffall On 08/19/2024 at 03:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: AMBER CARE HOME
FACILITY NUMBER: 107209123

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation Medication Fludrocortisone .1 MG tablets, Dosage Instructions: 1 tablet per day, daily. Instructions were written in Mars by staff and not by the Dr. or Pharmacy which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2024
Plan of Correction
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Licensee agrees to have all staff retrained in Medication training and submit written documentation upon completion of training. Licensee agrees to have any changes of medication be written in the MARS and Medication log be written by a Licensed Physician.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:See Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024


LIC809 (FAS) - (06/04)
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