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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200732
Report Date: 08/02/2022
Date Signed: 08/02/2022 03:14:11 PM

Document Has Been Signed on 08/02/2022 03:14 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: 9DATE:
08/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Benjamin Blake, AdministratorTIME COMPLETED:
03:25 PM
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On 8/2/2022 starting at 1:55 p.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator Benjamin Blake and disclosed the purpose of the visit.

Upon entry, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, bathrooms, kitchen, and common areas. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette and some hand washing posters were observed. Most of facility staff were observed to be wearing proper PPE.

Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff, and visitors.

No deficiency cited during visit. Exit interview conducted with Administrator, and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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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