079200582-7-12-2024-15-AS-BFOG-D7GUFR-20240724153311

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200582
Report Date: 07/12/2024
Date Signed: 07/12/2024 01:14:01 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
07/02/2024 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20240702084132

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:	07/12/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Raufat Ikharo-Umaru, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff made inappropriate comments towards resident
Staff yelled at resident

INVESTIGATION FINDINGS:

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On 07/12/24 at 11:30AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced visit, interviewed staff (ADM, S1) and resident (R1), gathered information and delivered the investigation findings to the administrator (ADM). LPA explained the purpose of the visit with ADM.

During investigation, the department obtained the following documents from the facility: Personnel record (LIC500), Residents’ roster with contact information, R1, R2 admission agreements, Needs & Services Plans, staff training certifications.

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: 07/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240702084132

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: 07/12/2024

NARRATIVE

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At 12PM, LPA spoke with R1 who stated that staff treat her well, do not call her names and do not yell at her. She stated that on 07/02/24 she was awoken from her sleep to eat breakfast by the caregiver and had an exchange of words with the ADM on the phone. She stated that both ADM and herself settled their differences and apologized to staff.

R1 stated staff do not yell at her or call her names. LPA also interviewed staff (ADM, S1) who stated that R1 yells and makes inappropriate comments towards them whenever she is agitated or depressed.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation(s) that staff made inappropriate comments towards resident and that staff yelled at resident were found to be unsubstantiated.

No deficiencies 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: 07/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024

LIC9099 (FAS) - (06/04)

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