079200582-3-15-2024-15-AS-KHOS-D45RFH-20240408125910

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200582
Report Date: 03/15/2024
Date Signed: 03/15/2024 12:53:23 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/27/2024 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20240227115411

FACILITY NAME:	AMBASSADOR CARE HOME		FACILITY NUMBER:	079200582
ADMINISTRATOR:	IKHARO-UMARU, RAUFAT		FACILITY TYPE:	740
ADDRESS:	145 BEEDE WAY		TELEPHONE:	(510) 812-2188
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	6	CENSUS: 5	DATE:	03/15/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Raufat Ikharo-Umaru, Administrator Claire Nayiga, Caregiver		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Illegal eviction of resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 03/15/24 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit, met with staff (S2) and spoke to administrator (ADM) on the phone who authorized S2 to act on her behalf and sign the reports. LPA explained the purpose of the visit with staff (ADM, S2) and delivered investigation finding.

During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, pre-placement appraisal, admission agreement, physicians report, hospice care plan, needs & services plans, 30-day written eviction notice.

Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 15-AS-20240227115411

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AMBASSADOR CARE HOME	FACILITY NUMBER: 079200582
	VISIT DATE: 03/15/2024

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
26
27
28
29
30
31
32

Allegation: Illegal eviction of resident
Investigation Finding: Unsubstantiated
During investigation, ADM denied illegally evicting resident (R1). On 02/29/24 at 12PM, LPA observed R1 still residing at the facility and witnessed him urinate on the floor while wandering in the common hallway. Staff (ADM, S2) assisted R1 immediately, changed his diaper/clothes and redirected him back to his bedroom. Review of resident’s (R1’s) admission agreement showed R1 was first admitted at the facility on 01/03/24.

ADM stated that she has communicated R1’s higher level of care needs several times with R1’s responsible party (POA) since January 2024 with no response. Review of R1’s documents showed that ADM sent a written 30-day notice of eviction to R1’s POA and County Conservator dated 02/29/24 for non- payment of monthly basic fees and additional services from 01/03/24 until current. On 03/15/24 at 12:35 PM, LPA observed R1 relaxing inside his bedroom. ADM stated she is working with R1’s County Conservator in safely relocating R1.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of illegal eviction of resident and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation of illegal eviction of resident is unsubstantiated.

No deficiency cited during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2