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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800153
Report Date: 06/30/2021
Date Signed: 06/30/2021 10:21:24 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:AMBER HOUSEFACILITY NUMBER:
496800153
ADMINISTRATOR:TERESITA ASTUDILLOFACILITY TYPE:
740
ADDRESS:6151 GABRIELLE DRIVETELEPHONE:
(707) 837-0222
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:6CENSUS: 5DATE:
06/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Teresa AstudilloTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct an Annual Required inspection and met with Administrator, Teresa Astudillo. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA signed in and was provided a thermometer to take their temperature. Temperature was documented and thermometer was disinfected after use. LPA conducted a walk-through of the facility started at approximately 9:15am and observed the following: Facility has Covid-19 posters throughout including hand washing signs in restrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was observed in a centralized location. Facility does not keep hand sanitizer in resident rooms as a safety precaution. Per Administrator, they regularly discuss infection control with residents and staff. Staff remind residents to wash their hands and assist those who need help with hand washing. Staff had masks on during this visit. Per conversation with Administrator, facility is checking resident temperatures two time per day and staff when they come on shift Temperatures are documented for each resident and staff. LPA observed five residents in care with two sitting at the dining room table and all others in their rooms. Facility staff have completed PPE training and have been N-95 Fit tested. Facility is disinfecting frequently touched surfaces at least once per day.

Facility has submitted and received approval for their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. Additional PPE is located off-site. Facility maintains a 30 day supply of medication.


Continued on LIC809C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: AMBER HOUSE
FACILITY NUMBER: 496800153
VISIT DATE: 06/30/2021
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Continued from LIC809

100% of staff and 100% of residents are vaccinated so facility is no longer conducting surveillance testing per CCL guidance. LPA and Administrator discussed the facility visitation policy and activities provided for residents. Facility has designated an outdoor area for visitation. LPA asked Administrator to review PINs 21-17-ASC and 21-17.1-ASC for guidance regarding visitation, communal dining, ect.

Administrator and LPA discussed their Emergency Disaster Plan. Smoke alarms are hardwired and were tested during inspection.



No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021
LIC809 (FAS) - (06/04)
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