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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800153
Report Date: 07/03/2024
Date Signed: 07/03/2024 04:27:45 PM

Document Has Been Signed on 07/03/2024 04:27 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:AMBER HOUSEFACILITY NUMBER:
496800153
ADMINISTRATOR/
DIRECTOR:		TERESITA ASTUDILLOFACILITY TYPE:
740
ADDRESS:6151 GABRIELLE DRIVETELEPHONE:
(707) 837-0222
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6CENSUS: 5DATE:
07/03/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Staff Member, Andrew Cunha, and Designated Representative, Guadalupe RiveraTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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At approximately 2:30PM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a 1-Year Required Visit and met with Staff Member, Andrew Cunha. Designated Representative, Guadalupe Rivera, arrived during visit at approximately 2:40PM. Facility serves older adults and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for 6 non-ambulatory residents of which 1 resident can be bedridden. Facility has an approved hospice waiver for 1 individual. Upon arrival, LPA was informed that there were 5 Residents in care and 2 staff members on-site.

LPA reviewed medications and conducted interviews. Medications were centrally stored and secure.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Designated Representative. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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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