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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800153
Report Date: 06/10/2022
Date Signed: 06/10/2022 11:17:09 AM


Document Has Been Signed on 06/10/2022 11:17 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 4DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator, Teresa AstudilloTIME COMPLETED:
11:30 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 Administrator took LPA's temperature and documented it. LPA confirmed with Administrator that staff are conducting vaccination verification of visitors per Provider Information Notice (PIN) 21-40-ASC. LPA conducted a walk-through of the facility at approximately 10:20am and observed the following: Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected twice per day. Facility check resident's temperatures twice per day and staff are screened when they arrive on shift. Facility maintains documentation of staff and resident daily temperatures. Facility has removed some of their Covid-19 posters including hand washing signs in the bathrooms. LPA has asked that hand washing signs are put back up in bathrooms.

Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff have completed PPE training and have been N95 fit tested.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Additional PPE is stored off-site. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced May 2022. Smoke and carbon monoxide detectors throughout facility were tested and operational.


Continued on LIC809C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AMBER HOUSE
FACILITY NUMBER: 496800153
VISIT DATE: 06/10/2022
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Continued from LIC809

Administrator and LPA discussed their Emergency Disaster Plan and the Infection Control Plan. Infection Control Plans are to be sent to CCL no later than June 30, 2022.

Licensee/Administrator to submit updates of the following documents by 7/10/2022:
LIC 308 Designated Administrator
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if there are changes)
LIC 9020 Register of Facility Resident’s
Copy of Liability Insurance

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: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC809 (FAS) - (06/04)
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