198320125-11-3-2023-11-AS-LVIS-CX8L4T-20231103082605

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320125
Report Date: 11/02/2023
Date Signed: 11/03/2023 08:26:14 AM

Document Has Been Signed on 11/03/2023 08:26 AM - 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	AMBER VILLE		FACILITY NUMBER:	198320125
ADMINISTRATOR:	ABDULLAH, SITI KHATIJAH		FACILITY TYPE:	740
ADDRESS:	2314 E. POPPY STREET		TELEPHONE:	(562) 881-9464
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90805
CAPACITY:	3	CENSUS: 0	DATE:	11/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Administrator Siti Khatijah Abdullah		TIME COMPLETED:	03:44 PM

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On 11/02/23, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Siti Khatijah Abdullah and explained the purpose of today’s visit. The facility is licensed to serve 3 non ambulatory elderly adults ages 60 and over, of which 1 may be bedridden. Bedridden in bedroom 1 or 2. Hospice waive for 3. There are currently (0) residents in care.

The facility is a single-story structure located in a residential neighborhood and consists of the following: 6 bedrooms , 3 bathrooms, living, dining, kitchen, pantry and activity/den areas, a two (2) car garage. The passageways, walkways and steps are free from obstructions.

Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew. The water temperature properly measured between 105-120 F.

During today’s 1 discrepancies was observed and documented on 809 D.

Exit interview conducted with Administrator Siti Khatijah Abdullah, appeal rights explained, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

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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Document Has Been Signed on 11/03/2023 08:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMBER VILLE	FACILITY NUMBER: 198320125
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

1569.605

1569.605 Liability insurance; coverage requirements On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: there is no record of liability insurance.
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above as facility does not have required liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/16/2023
	Plan of Correction
1 2 3 4	Administrator will obtain liability insurance and submit proof to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

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