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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200732
Report Date: 12/05/2022
Date Signed: 12/05/2022 02:09:48 PM

Document Has Been Signed on 12/05/2022 02:09 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:BENJAMIN BLAKE, ADMINISTRATORTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) C. Lin conducted case management and met with Administrator and program manager and explained the purpose of visit.

On today visit 12/5/22, during the course of investigation on a complaint, the Department observed that Covid-19 outbreak with 5 positive cases started in the facility on 11/27/2022 that was not reported to CCLD. Staff (S7) stated that the outbreak was reported to the county public health in a timely manner, public health has involved and provided further instruction. However, S7 was not aware that reporting to CCLD was required.

A broken door of client's room was observed during visit. Staff S6, S8, and S9 stated that the door has been broken since Thanksgiving, and S7 was not aware of until today's date.

Deficiencies are 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 violation within 12 month period may result in addition civil penalty.



Exit interview conducted with program manager, LIC809D, 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
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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Document Has Been Signed on 12/05/2022 02:09 PM - It Cannot Be Edited


Created By: Catherine Lin On 12/05/2022 at 01:23 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: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2022
Section Cited
CCR
80061(b)(1)(H)

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80061 REPORTING REQUIREMENTS
(b) …any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report…shall be submitted to the licensing agency within seven days…
(1) Events reported shall include the following:
(H) Epidemic outbreaks.
This requirement is not met as evidenced by…
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Administrator agrees to review regulation of reporting requirement, train staff, and submit proof of training record with staff signatures to CCL by the POC due date.
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Based on observation, records review, and interview, the licensee did not comply with the section cited above. Covid-19 outbreak started on 11/27/22 was not reported to CCLD which posed a potential health, safety or personal rights risk to persons in care.
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Type B
12/12/2022
Section Cited
CCR80087(a)

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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidenced by…
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Administrator agrees to have the door repair and send picture to CCL by the POC due date.
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Based on observation and interview, the licensee did not comply with the section cited above. The broken door of client room was observed which posed a potential health, safety or personal rights risk to persons in care.
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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: 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


LIC809 (FAS) - (06/04)
Page: 2 of 2