374604433-6-17-2021-08-AS-DCOA-C43TSX-20210617145952

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604433
Report Date: 06/16/2021
Date Signed: 06/17/2021 03:07:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	AMBER HOMECARE CORP.		FACILITY NUMBER:	374604433
ADMINISTRATOR:	TAGORDA, JEROME MR.		FACILITY TYPE:	740
ADDRESS:	7417 COWLES MOUNTAIN BLVD		TELEPHONE:	(706) 280-3930
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92119
CAPACITY:	6	CENSUS: 0	DATE:	06/16/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Licensee, Jerome Tagorda		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Debbie Correia, conducted an announced Pre-licensing and Component IIl visit at a Residential Facility for the Elderly (RCFE) to ensure compliance with California Code of Regulations, Title 22, Division 6 and the Health and Safety Code. LPA Correia identified herself to Applicant, Jermone Tagorda and explained the purpose of the visit. The fire inspection was completed on May 18, 2021 by the San Diego Fire Department. Facility was cleared for six residents ages 60 and above, five (5) that may be non-ambulatory, and one (1) of which may be bedridden in dedicated bedroom, only. During today's visit LPA Correia, accompanied by Applicant, Jerome Tagorda, conducted a tour of the facility. According to Applicant Tagorda there will be no firearms or ammunition stored on site. No pools or bodies of water were observed. Indoor and outdoor passageways are free from obstructions. All window screens are clean and in good repair. Hallways are well-lit and night lights are available in the hallways. Fire, smoke alarms, and carbon monoxide detectors were all observed and operational. There is a bed for each resident's bedroom, equipped with padded covered mattresses, and pillows, observed clean and in good repair. There is sufficient closet and drawer space for resident belongings. Each resident bedroom is furnished with a chair, lamp, and a night stand. Resident bathrooms are also in good repair, equipped with handrails, Showers were equipped with non-skid shower mats. The facility maintains a sufficient supply of clean linens, sheets, bedspreads, blankets, pillowcases, mattress covers, hand towels, and washcloths. LPA Correia observed a seven-day supply of non-perishable foods and a sample of the facility meal menu. The facility kitchen also maintains sufficient amounts of clean utensils, and equipment for proper storage of food items, and locked storage for sharp items (i.e. knives). LPA Correia observed an area for confidential storage area for personnel and resident records, as well as a locked storage cabinet for residents' medications. Emergency exit plans, facility policy, and residents' personal rights are posted in prominent areas. There is a shaded outdoor activity space, a common room available for visitors, and appropriate activity supplies.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: AMBER HOMECARE CORP.	FACILITY NUMBER: 374604433
	VISIT DATE: 06/16/2021

NARRATIVE

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LPA observed a first aid kit maintained at the facility and proof of purchase of the first aid manual. The facility garage remains locked when not in use, and also has a locked area to store cleaning/laundry supplies and other toxic chemicals. LPA Correia obtained an order for installation of a land line via Cox Communications. There is emergency lighting and supplies readily available for safety measures. The hot water temperature measured with in compliance (116.9 and 109.3 degrees F) in facility bathrooms, and the central air unit was at 76 degrees. Applicant Targoda's Administrator's Certification expires on September 30, 2021 .

Component III was conducted at the facility with applicant Targorda. LPA Correia reviewed continuing operational requirements, as well as record keeping and physical plant compliance. The applicant shall contact the Centralized Application Bureau (CAB) for completion of this pending facility application. Based on today's evaluation, the facility is in compliance with CCR, T22 and the Health and Safety Code. Final approval is forwarded to management pending review. Pre-licensing inspection is complete and the facility has no deficiencies.

An exit interview was conducted, and a copy of this report, and Licensee's Rights (9058 01/16) will be sent to the Applicant's e-mail address. An electronic mail read receipt confirms delivery and receipt of these documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC809 (FAS) - (06/04)

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