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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200732
Report Date: 12/05/2022
Date Signed: 12/05/2022 02:05:44 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/30/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221130103247
FACILITY NAME:AMBER HOUSE CRISIS RESIDENTIALFACILITY NUMBER:
019200732
ADMINISTRATOR:BENJAMIN BLAKEFACILITY TYPE:
772
ADDRESS:516 31ST STTELEPHONE:
(510) 379-4394
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY:16CENSUS: 7DATE:
12/05/2022
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:BENJAMIN BLAKE, ADMINISTRATORTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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9
Licensee allows staff to work at facility without fingerprint clearance
INVESTIGATION FINDINGS:
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On 12/5/2022 at 9:05AM, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct an initial 10-day complaint investigation in regard to the allegation above, and respectfully delivered investigation findings. LPA met with program manager and informed him the reason for visit. Administrator arrived at a later time.

Allegation - Licensee allows staff to work at facility without fingerprint clearance– Substantiated
The Department has investigated this allegation and per records review and interviews, 5 staff members (S1, S2, S3, S4, and S5) didn’t have fingerprint clearance and have been scheduled to work. Administrator admitted that staff who have not been associated with facility were called to work due to staff shortage.


Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 15-AS-20221130103247
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AMBER HOUSE CRISIS RESIDENTIAL
FACILITY NUMBER: 019200732
VISIT DATE: 12/05/2022
NARRATIVE
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Based on information obtained, the preponderance of evidence is met, therefore the allegation is substantiated.

Deficiency is cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result an addition civil penalty. Civil Penalty $2500 is assessed on today's date.

Deficiency and plan and proof of correction were discussed with the program manager as Administrator was not available at the moment.

Exit interview conducted with program manager, LIC9099D, Appeal Rights, and copy this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20221130103247
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AMBER HOUSE CRISIS RESIDENTIAL
FACILITY NUMBER: 019200732
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2022
Section Cited
CCR
80019(e)
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80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility.

This requirement is not met as evidenced by…
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Administrator agrees to either remove uncleared staff or have them work with cleared staff until uncleared staff have associated with facility. Administrator will provide self-certification to CCL by the POC due date.
In addition, Administrator agrees to associate these 5 staff members in the next 14 days and provide proof to CCL by 12/19/22.
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Based on observation, record review, and interview, the licensee did not comply with the section cited above. Administrator admitted that 5 staff members have been working at the facility without fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.
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Civil Penalty $2500 is assessed.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/30/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20221130103247

FACILITY NAME:AMBER HOUSE CRISIS RESIDENTIALFACILITY NUMBER:
019200732
ADMINISTRATOR:BENJAMIN BLAKEFACILITY TYPE:
772
ADDRESS:516 31ST STTELEPHONE:
(510) 379-4394
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY:16CENSUS: 7DATE:
12/05/2022
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:BENJAMIN BLAKE, ADMINISTRATORTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Licensee is not providing enough food to meet clients' needs
INVESTIGATION FINDINGS:
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Allegation - Licensee is not providing enough food to meet clients' needs– Unsubstantiated.

The Department has investigated this allegation and per observation and interviews, and found that adequate food supplies were observed during visit. 3 clients who were interviewed stated that facility provided pretty of food and they have never been hungry.

Based on observation and interview conducted, the above allegation is unsubstantiated. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4