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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200732
Report Date: 08/20/2021
Date Signed: 08/20/2021 02:49:07 PM

Document Has Been Signed on 08/20/2021 02:49 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:AMBER HOUSE CRISIS RESIDENTIALFACILITY NUMBER:
019200732
ADMINISTRATOR:ALEXANDRA ALI BALLARD,LCSWFACILITY TYPE:
772
ADDRESS:516 31ST STTELEPHONE:
(510) 379-4394
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 16CENSUS: DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Haeyoung Sohn, AdministratorTIME COMPLETED:
02:55 PM
NARRATIVE
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On August 20, 2021, at 10:10am, Licensing Program Analysts (LPAs) Catherine Lin and Alicia Delmundo conducted an unannounced annual required/infection control inspection, and met with the facility staff, Aaron Stout, and informed the purpose of visit. LPAs were granted entry into the facility by Aaron. Both Aaron and LPAs spoke with the regional director Margaret Shapior on the phone. Margaret stated that Heayoung Sohn is the new administrator and she would be arriving by 11am. Heayoung arrived at 11:08am. LPAs also met with another staff, Benjamin Blake.

LPAs temperature was checked by the machine but has not been recorded, no screening questions asked and no visitors log.

Heayoung and Blake accompanied LPAs inside and out the facility during inspection.

LPAs verified and Heayoung stated she took over the position of administrator two months ago and the documents for change in administrator have not been submitted to Community Care Licensing (CCL).

Continue writing narrative on LIC809C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AMBER HOUSE CRISIS RESIDENTIAL
FACILITY NUMBER: 019200732
VISIT DATE: 08/20/2021
NARRATIVE
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LPA inspected the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives, medication and toxic were kept in locked storage cabinet. Fire extinguisher checked, observed fully charge and last serviced March 11, 2021. A two-in-one carbon monoxide and smoke detector tested and observed sworking.

During the inspection, LPAs observed the following:

  • Some trash bins with no lids.
  • Hand-washing signs are missing in all bathrooms.
  • No visitor's log.
  • Outdated visitor's poster
  • PPE supplies not sufficient for 30 days.
  • Facility has not completed the N95 it testing for some staff.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date and any repeat violations within 12 months may result in civil penalties.

Exit interview conducted. Plan and proof of correction were reviewed and developed with the Haeyoung Sohn. Copy of this report and appeal rights provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2021 02:49 PM - It Cannot Be Edited


Created By: Catherine Lin On 08/20/2021 at 01:21 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AMBER HOUSE CRISIS RESIDENTIAL
FACILITY NUMBER: 019200732

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81061(j)

81061 REPORTING REQUIREMENTS
(j) The licensee shall notify the licensing agency, in writing, within 10 working days of a change of administrator or program director. Such notification shall include the following

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. The facility has new administrator but the change was not reported to CCL which posed a potential health, safety and personal rights risk to persons in care.
POC Due Date: 09/03/2021
Plan of Correction
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Licensee to submit the following by 09/03/21:
1. Board Resolution
2. Proof of administrator qualifications
3. LIC501 Personnel Record
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:Bennett Fong
LICENSING EVALUATOR NAME:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2021


LIC809 (FAS) - (06/04)
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