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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209123
Report Date: 03/29/2022
Date Signed: 03/29/2022 12:10:22 PM

Document Has Been Signed on 03/29/2022 12:10 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, 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: 3DATE:
03/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator Alex Babakhani and Pacita BaltazarTIME COMPLETED:
11:30 AM
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On 03/29/22, Licensing Program Analyst (LPA) M. Yang conducted an unannounced case management inspection regarding incident report received from facility on 3/11/22. LPA met with caregiver Margarita Linares. Administrator Alex Babakhani and Pacita Baltazar was called and arrived shortly.

The purpose of the today's visit is to follow up on the incident report that was submitted to department on 03/11/22. Staff did not initial Medication Administration Record (Mar) on 03/02/22 after administering medication to R3. LPA interviewed staffs and reviewed records. No further action needed regarding this incident at this time.

LPA follow up on report department received regarding R3 expressed having difficult eating due to gum soreness from unfitted dentures. LPA interview staffs and resident. No further action needed regarding this incident at this time.

LPA follow up on incident report that was reported on 03/11/22. R1 did not receive medication, Calcium, as directed during bedtime in the month of February 2022. R2 did not receive Vitamin C in the evening for the month of January 2022.

Licensee reported incidents occurred on 01/01/22- 02/27/22 and 03/02/22 to department on 03/11/22.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D.

Exit Interview conducted. As a COVID-19 precautionary measure, a copy of this report and appeal rights will be provided via email. Report signed on site.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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 03/29/2022 12:10 PM - It Cannot Be Edited


Created By: Mai Yang On 03/29/2022 at 10:38 AM
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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: AMBER CARE HOME
FACILITY NUMBER: 107209123

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2022
Section Cited
CCR
87465(a)(5)

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87465(a)(5) Incidental Medical and Dental Care The licensee shall assist residents with self-administered medications as needed.

This requirement was not met as evidenced by:
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Licensee has staff retrained on administering medication. Copy of training on 03/05/22 provided to LPA.
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Based on interviews and records review, the licensee did not ensure staff administering R1 Calcium during bedtime on 02/01/22-02/27/22. R2 did not received Vitamin C in the evening from 01/01/22-01/31/22 which poses an immediate health and safety risks to persons in care.
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A has a plan of correction with an action plan that included facility MAR to be reviewed by Administrator and ongoing staff training on administering medications will be submitted to department by 03/30/22.
Type B
04/04/2022
Section Cited
CCR87211(a)(1)

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87211 (a)(1) Reporting Requirements (a) Each licensee shall furnish to the licensing agency... (1) A written report...to the licensing agency and to the person responsible for the resident within seven days of the occurrence.

This requirement was not met as evidenced by:

This requirement was not met as evidenced by:
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Licensee agrees to submit a plan detailing steps the facility will take to ensure incident reports are submitted to the Fresno CCL office and responsible party. The plan will be submitted to the Fresno CCL office by 03/04/22.
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Based on record reviews, Incident report that incident occurred 01/01/22-01/31/22, 02/01/22-02/27/22, and 03/02/22 was reported to department on 03/11/22. This poses a potential health and safety 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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022


LIC809 (FAS) - (06/04)
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