496800153-6-6-2024-21-AS-CFES-D5YULW-20240606154125

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800153
Report Date: 06/06/2024
Date Signed: 06/06/2024 03:41:37 PM

Document Has Been Signed on 06/06/2024 03:41 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	AMBER HOUSE		FACILITY NUMBER:	496800153
ADMINISTRATOR:	TERESITA ASTUDILLO		FACILITY TYPE:	740
ADDRESS:	6151 GABRIELLE DRIVE		TELEPHONE:	(707) 837-0222
CITY:	WINDSOR	STATE: CA	ZIP CODE:	95492
CAPACITY:	6	CENSUS: 5	DATE:	06/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Staff Member, Mariana Sanchez, and Designated Representative, Guadalupe Rivera		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	At approximately 8:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Staff Member, Mariana Sanchez. Designated Representative, Guadalupe Rivera, arrived during visit at approximately 9:00AM. Licensee, Christine Woltering, arrived during visit at approximately 1:40PM. Facility serves older adults and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for 6 non-ambulatory residents of which 1 resident can be bedridden. Facility has an approved hospice waiver for 1 individual. Upon arrival, LPA was informed that there were 5 Residents in care and 2 staff members on-site. At approximately 8:45AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA also observed that the significant other of a staff member lived on-site. Review of Facility's Staff Roster indicated that this individual was not on the Facility's Staff Roster. Per conversation with facility staff, this individual does not provide direct care to the residents. LPA confirmed on the Guardian website that this individual was background cleared but not associated to the facility as required. LPA observed individual be associated during visit. Administrator understands that a civil penalty is not being issued today for individual because they were associated to the facility during visit. At approximately 9:35AM, LPA conducted a walk-though of the facility with Designated Representative. Per Facility sketch, facility is a one story building with 6 bedrooms, 3 bathrooms, and common spaces. During visit, LPA observed a granny unit on-site that was not indicated on the facility sketch. LPA and Designated Representative discussed submitting an updated facility sketch (see Technical Violation, LIC9102, Regulation 87208(a)(7)(A)). Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. Continued on LIC809C

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AMBER HOUSE	FACILITY NUMBER: 496800153
	VISIT DATE: 06/06/2024

NARRATIVE

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Continued from LIC809

There was a sufficient supply of perishable foods as required by Title 22 Regulations. LPA and Designated Representative discussed having at least 7 days of non-perishable foods available for residents (see LIC9102, Technical Advisory, regulation 87555(b)(26)). There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Hot water temperatures for all sinks were found to be out of compliance with Title 22 Regulations, measuring at 126.6F, 129.7F, 129.0F, 131.3F, 130.6F, and 131.9F (this deficiency has been cited, see LIC809D, Regulation 87303(e)(2)). Facility's fire extinguishers were last inspected April 2024. Facility's last emergency/disaster drill was conducted May 2024.

At approximately 11:15AM, LPA reviewed staff files and resident files. Staff Files were found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. During Resident File Review, LPA observed that 1 of 5 residents did not have an updated annual Physician's Report as required for individuals with dementia (this deficiency has been cited, See LIC809D, Regulation 87705(c)(5)). LPA conducted interviews.

Administrator's Certificate for Christine Woltering (6033992740) was current with an expiration date of 02/25/2025. Administrator's Certificate for Zoe Wildgust (7020635740) was current with an expiration date of 10/10/2025.

LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Designated Representative. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/06/2024 03:41 PM - 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AMBER HOUSE	FACILITY NUMBER: 496800153
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the Licensee did not comply with the section cited above. LPA observed that 1 of 5 residents did not have an updated annual physician's report as required for residents with a dementia diagnosis. This poses a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 06/17/2024
	Plan of Correction
1 2 3 4	Licensee scheduled physician's appointment for 06/10/2024. Licensee to submit resident's updated physician's report for 2024 to CCL when received by POC due date of 06/17/2024.

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: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/06/2024 03:41 PM - 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AMBER HOUSE	FACILITY NUMBER: 496800153
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Licensee did not comply with the section cited above. Licensee did not ensure that water temperatures for all sinks in facility were within Title 22 regulations of 105F to 120F. Sinks were observed to be the following temperatures: 126.6F, 129.0F, 131.3F, 130.6F, and 131.9F. This poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 06/07/2024
	Plan of Correction
1 2 3 4	Licensee to submit a self-certification stating that a water temperature log for 10 days for all sinks in facility will be done. Certification to be submitted by POC due date of 06/07/2024.Temperature to be checked twice a day starting 06/07/2024 and ending 06/17/2024. Log to include time when water was checked. Log to be submitted to CCL for review and approval by POC due date 06/17/2024.

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: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

LIC809 (FAS) - (06/04)

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