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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603575
Report Date: 12/19/2023
Date Signed: 12/19/2023 01:01:23 PM


Document Has Been Signed on 12/19/2023 01:01 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:AMBER AUTUMN BOARD & CAREFACILITY NUMBER:
198603575
ADMINISTRATOR:MARTIN, TRACYFACILITY TYPE:
740
ADDRESS:19974 E. LIMECREST DR.TELEPHONE:
(626) 833-1384
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:5CENSUS: 0DATE:
12/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Tracy Martin, Licensee/ administratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Licensee Tracy, who assisted with the visit. The facility is licensed to serve elderly, ages 60 years old and older and has two (2) approved hospice waiver. The facility capacity is five (5) including three (3) ambulatory, two (2) non- ambulatory and zero (0) bedridden. The facility has dementia program in place. Annual fees are current. Administrator certificate is current with expiration date on 6/12/24. LPA discussed the purpose of today's visit with Licensee / administrator, Tracy.

During the visit, LPA conducted staff interview, used CARE inspection tool, toured the facility, reviewed food supply, and reviewed staff records. Since the facility has not admitted resident, thus, resident interview, resident record review and medication were not conducted.



The facility is a two-story house with four (4) resident bedrooms, one (1) staff bedroom, four (4) bathrooms, living room, kitchen, dining room, family room, backyard with patio, activity area in the garage, and laundry room. The resident bedrooms are spacious and will easily accommodate with the resident’s furnishings. Exits are installed with alarm auditory devices.

(-continued in LIC 809 C-)

SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: AMBER AUTUMN BOARD & CARE
FACILITY NUMBER: 198603575
VISIT DATE: 12/19/2023
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Medication will be centrally stored in a locked medication cabinet and inaccessible to residents in care. All rooms are furnished with appropriate furniture for residents’ comfort. Bathrooms are furnished with grab bars and nonskid surfaces. Common areas and outdoor areas are observed for the ability to safely serve the needs of the residents. Hot water temperature is 118.2 degrees Fahrenheit which was within Title 22 Regulation guidelines.

Sufficient of linen supplies and personal hygiene supplies were observed. Sufficient supply of perishable and non-perishable foods was observed. Refrigerators, freezers, microwaves, ovens and counter tops observed to be clean. Plates, cups, glasses and utensils are sufficient for the current census.

Smoke detectors and carbon monoxide detectors were tested and operable. Fire extinguishers were fully charged. All mandated documents and signages are posted in common areas.



No deficiency was cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report is discussed and provided to Licensee Tracy, whose signature on this form confirm receipt of these documents.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC809 (FAS) - (06/04)
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