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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201064
Report Date: 05/18/2022
Date Signed: 05/18/2022 01:41:25 PM


Document Has Been Signed on 05/18/2022 01:41 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:AMBER CARE HOMEFACILITY NUMBER:
079201064
ADMINISTRATOR:DEL ROSARIO, ANATOLIAFACILITY TYPE:
740
ADDRESS:3744 PINTAIL DR.TELEPHONE:
(925) 706-9922
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 5DATE:
05/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Amy Burton, Licensee/AdministratorTIME COMPLETED:
02:00 PM
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On 05/18/2022 at 12:40pm Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct infection control inspection. LPA met with licensee/administrator and explained the purpose of the visit

During the Infection Control Inspection, LPA toured facility including but not limited to common areas, kitchen, bedroom, and shared bathrooms, front entrance, screening station, hand washing stations, common areas. There is one central entry point for universal screening for staff, residents and visitors.

A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing signs were posted in common areas. Hand washing posters, soap, and paper towel were observed at hand washing stations. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Visitors policy is posted on the front door.

Facility staff were observed wearing masks. Facility has a 30-day supply of PPE maintained at a central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. Infection control leader is the administrator.

Continued on next page, LIC 809-C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AMBER CARE HOME
FACILITY NUMBER: 079201064
VISIT DATE: 05/18/2022
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 05/19/22:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC809 (FAS) - (06/04)
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