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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209123
Report Date: 10/11/2023
Date Signed: 10/11/2023 02:29:58 PM


Document Has Been Signed on 10/11/2023 02:29 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:AMBER CARE HOMEFACILITY NUMBER:
107209123
ADMINISTRATOR:BABAKHANI,ARDALAN ALEXFACILITY TYPE:
740
ADDRESS:399 AMBER AVE.TELEPHONE:
(559) 392-0393
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 4DATE:
10/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Administrator Pacita Baltazar and Caregiver Marqarita “Rita” Linares TIME COMPLETED:
02:00 PM
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On 10/11/23, Licensing Program Analysts (LPA) M. Yang and L. Padgett arrived unannounced to conduct an annual visit. LPAs introduce self, stated the purpose of the visit and request to meet with Administrator. LPAs met with caregiver Marqarita “Rita” Linares and toured facility. Administrator Pacita Baltazar was called and arrived shortly during tour. One resident was present during inspection.

The facility was observed to be at a comfortable temperature of 74 degrees F, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Temperature maintained for refrigerator at 39 degrees F and freezer at 0 degrees F. An adequate supply of perishable and non-perishable food was observed. Medications observed kept locked in kitchen shelf. MARs were reviewed. Fire extinguisher was observed with a service date of: 04/02/2023. Fire drill last completed: 07/18/2023. Cleaning supplies and chemicals stored and locked in laundry closet. Washer and dryer was observed operational during inspection.All bedrooms were observed to have required furnishings and with adequate lightening. Bathrooms were properly equipped and operational. All bathrooms are observed with securely fastened grab bars and non-skid mat. Hot water temperature was tested range 113.5 and 115.3 degrees in bathroom 1 and range 117.3 and 117.7 degrees F in bathroom 2.

Outside of facility toured and observed to be free of debris. Side gate observed self-closing and self-latching. Carbon monoxide and smoke detectors were tested and observed to be operational. All residents’ file reviewed to have update emergency contacts, Admission agreement, Physician report, and IPP. Staff files were also reviewed. Staff files were observed to have current First Aid/CPR, health screening, fingerprinted clear and associated to the facility.

No deficiency cited during inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 10/17/23. Forms requested: Lic 308, Lic 400, Lic 402, Lic 500, Lic 610E, and current liability insurance. A copy of this report was provided to the Administrator whose signature on this form confirms receipt of this report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
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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