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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603575
Report Date: 10/07/2022
Date Signed: 10/07/2022 12:32:55 PM

Document Has Been Signed on 10/07/2022 12:32 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:AMBER AUTUMN BOARD & CAREFACILITY NUMBER:
198603575
ADMINISTRATOR:MARTIN, TRACYFACILITY TYPE:
740
ADDRESS:19974 E. LIMECREST DR.TELEPHONE:
(626) 833-1384
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 5CENSUS: 0DATE:
10/07/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tracy Martin, applicantTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Tao conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA met Tracy Martin, applicant/administrator, who assisted with the visit. An application was submitted on 04/28/2022. It is an initial application applying for Residential Care Elderly to serve elderly, ages 60 years old and older. The requested capacity is five (5) including three (3) ambulatory, two (2) non- ambulatory and zero (0) bedridden. The applicant is Lady Baby Inc and applied for dementia program.

Structure: Facility is a two-story house with four (4) resident bedrooms, one (1) staff bedroom, four (4) bathrooms, living room, kitchen, dining room, family room, backyard with patio, activity area in the garage, and laundry room. Passageways, walkways, driveways, steps and patios are free from obstructions. The resident bedrooms are spacious and will easily accommodate with the resident’s furnishings. Exits are installed with alarm auditory devices.

Bedrooms for Residents: Bedrooms have beds, chairs, night stands, lamps in addition to overhead lighting. There are dressers with drawers.

Bathrooms: All bathrooms have a working toilet, wash basin, and shower with non-skid
mat and grip bar. ( - continued in LIC 809 C - )
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: AMBER AUTUMN BOARD & CARE
FACILITY NUMBER: 198603575
VISIT DATE: 10/07/2022
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Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in linen storage room.

Fire clearance: Approved Room #1 (downstairs) for two (2) non ambulatory residents; Room#2, #3 and #4 (upstairs) approved for one (1) ambulatory in each room. Fire clearance was approved on 06/17/22.

Smoke Detectors: Carbon monoxide detectors and smoke detectors are operable.

Water Temperature: Tested at 118.5 degrees Fahrenheit

Appliances: Stove burners, oven, microwave, washer, and dryer are working.

Medications: Medication drawer is locked and available to staff but inaccessible to
residents.

Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review at the entrance. Fire extinguishers located at kitchen and upstairs mounted on the wall. First Aid kit is observed.

Residents & Staff Files: Records of staff and residents are stored in a locked cabinet.
( - continued in LIC 809 C - )
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: AMBER AUTUMN BOARD & CARE
FACILITY NUMBER: 198603575
VISIT DATE: 10/07/2022
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Toxins: Toxic items and cleaning supplies are locked and stored in storage room.

No issues were observed during the visit.

Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted, and a copy of this report has been furnished to the applicant. Accordingly, LPA Tao will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC809 (FAS) - (06/04)
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