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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201064
Report Date: 06/17/2021
Date Signed: 06/17/2021 01:51:23 PM

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 CARE HOMEFACILITY NUMBER:
079201064
ADMINISTRATOR:DEL ROSARIO, ANATOLIAFACILITY TYPE:
740
ADDRESS:3744 PINTAIL DR.TELEPHONE:
(925) 706-9922
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 6DATE:
06/17/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Anatol Del Rosario, Administrator and Amalia Burton, LicenseeTIME COMPLETED:
01:35 PM
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On 06/17/2021 at 09:50am, Licensing Program Analyst (LPA) L. Hall conducted an announced pre-licensing inspection and met with Anatol Del Rosario, Administrator and Amalia Burton, Licensee. Facility has a fire clearance for six (6) non-ambulatory.

LPA toured the facility including but not limited to residents bedrooms, bathrooms, dining room, common living area, kitchen, garage, and backyard. There is sufficient lighting around the facility. Residents rooms are equipped with the proper furniture, lighting, and have proper bedding and linens. Bathrooms were equipped with grab bars and non-skid mats. All toxins and sharp objects are locked. Passageways and hallways are free of obstruction. Fire extinguisher was last serviced on 8/22/2020. Smoke detectors/ Carbon Monoxide detector were in operating condition during visit. Hot water temperature is measured at 117.1 degrees Fahrenheit. Emergency Disaster Plan was last posted on 01/01/2021. First aid kit was observed to be complete. This is an existing facility and 2-day perishable, and 7-day nonperishable are available for the residents.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
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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