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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200732
Report Date: 08/27/2024
Date Signed: 08/27/2024 03:11:47 PM

Document Has Been Signed on 08/27/2024 03:11 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:AMBER HOUSE CRISIS RESIDENTIALFACILITY NUMBER:
019200732
ADMINISTRATOR/
DIRECTOR:
BENJAMIN BLAKEFACILITY TYPE:
772
ADDRESS:516 31ST STTELEPHONE:
(510) 379-4394
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 16CENSUS: 8DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator Benjamin BlakeTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 8/27/2024 at 9:30 AM, Licensing Program Analysts (LPAs) J Sampair and D Doidge arrived unannounced to conduct the Required Annual Inspection. Upon entry, LPAs stated the purpose of the visit to Clinician Hisham Doumi. Administrator Ben Blake arrived at approximately 10:30 AM.

The LPAs inspected the interior and exterior of the facility. The inspection of the physical plant included the kitchen, dining area, restrooms, community living spaces, resident rooms, storage areas, and the grounds of the facility. More than the required minimum of 7 days of nonperishable and 2 days of perishable foods were appropriately stored. Temperature in the community living space was measured at 78.7 degrees Fahrenheit at 1:19 PM. The fire extinguisher was replaced 3/8/2024.

The carbon monoxide and smoke detectors were fully operational. The LPAs observed required postings in the facility, including the License, Planned Activities, and Meals. An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations.

The LPAs reviewed facility records, records of 5 residents, and records of 5 staff members. LPAs Interviewed 2 residents and 3 staff members.

No citations issued during inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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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