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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320109
Report Date: 11/04/2022
Date Signed: 11/04/2022 12:18:08 PM

Document Has Been Signed on 11/04/2022 12:18 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:AMBER ADULT RESIDENTIAL HOMEFACILITY NUMBER:
198320109
ADMINISTRATOR:CYRIL-EZIWHOU, CHIMENEM MFACILITY TYPE:
735
ADDRESS:19315 WEISER AVENUETELEPHONE:
(415) 374-0060
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: 4DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Cyril-Eziwhou ChimTIME COMPLETED:
12:45 PM
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On 11/04/22, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced Annual inspection visit with a primary focus on infection control measures, using the new Care Inspection Tool. LPA was met by Cyril-Eziwhou Chim, director, and the purpose of today’s visit was explained. The facility has an outstanding balance of $681.00 which was due on 09/25/2022, including a late penalty.

There are currently four (4) Regional Center consumers in placement. There are three (3) ambulatory and one (1) non-ambulatory in placement. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 2 bathrooms, living room, kitchen, dining room, shaded area, indoor and outdoor activity area, laundry room and an attached garage.

As part of the inspection, my primary focus was on infection control. LPA observed the facility’s infection control practices: LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff and residents, and additional supplies are stored. Sufficient paper, cleaning, and disinfecting supplies were observed.



LPA and Cyril toured the entire facility inside and out. All client bedrooms contain the mandated furniture, adequate lighting, and enough space to be comfortable. The bathrooms are clean and operational. Smoke detectors and carbon monoxide detector are complying and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Water temperature measured at 110.1 F.

Continued on LIC 809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMBER ADULT RESIDENTIAL HOME
FACILITY NUMBER: 198320109
VISIT DATE: 11/04/2022
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A comfortable temperature is maintained in the facility. Ample supply of perishable and nonperishable food, linens and personal hygiene supplies were observed. Hazardous toxins and/or items are inaccessible to clients, 2 fire extinguishers are fully charged. First Aid kit is complete with manual. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards.

The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff were wearing face coverings and required postings throughout the facility. LPA also observed that the facility has a 30-day supply of Personal Protective Equipment (PPE). And all mandated posters were posted.

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (cdss.ca.gov) for Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

The annual fees of $681.00 were paid while at the visit.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview was conducted with Cyril-Eziwhou Cim and copy of the Facility Evaluation Report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC809 (FAS) - (06/04)
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