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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200582
Report Date: 04/15/2025
Date Signed: 04/15/2025 05:29:35 PM

Document Has Been Signed on 04/15/2025 05:29 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:AMBASSADOR CARE HOMEFACILITY NUMBER:
079200582
ADMINISTRATOR/
DIRECTOR:		IKHARO-UMARU, RAUFATFACILITY TYPE:
740
ADDRESS:145 BEEDE WAYTELEPHONE:
(510) 812-2188
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
04/15/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:45 PM
MET WITH:Mbidde Nuhun, TIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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On 4/15/2025 at 2:50pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Mbidde Nuhun, unfingerprinted staff (S2). LPA spoke with Administrator, Raufat Ikharo-Umaru, via telephone. Administrator arrived at the facility at 4:35pm.

While LPA L. Hall was conducting a complaint investigation (15-AS-20241104220736) on 4/15/2025. Upon arrival LPA met with S2 at facility that was not able to communicate in English. Further investigation divulged S2 person was not fingerprinted or associated to the facility.

*An immediate civil penalty of $100.00 will be assessed on today's day for fingerprint clearance*

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the LIC421BG, appeal rights, and this report provided.
Harpreet HumpalTELEPHONE: (510) 285-3928
Laura HallTELEPHONE: (510) 622-2024
DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/15/2025 05:29 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: AMBASSADOR CARE HOME
FACILITY NUMBER: 079200582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2025
Section Cited
CCR
87355(d)

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87355 Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement under penalty of perjury. This requirement was not met as evidence by:
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Administrator agreed to have S2 fingerprinted and submit application to CCLD by POC date.
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Based on interview and record review the Licensee did not comply with the section cited above in having S2 fingerprinted and associated to the facility which poses an immediate health and safety risk to persons in care.
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Type A
04/16/2025
Section Cited
CCR87411(d)(3)

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(d) All personnel shall be given on the job training or have related experience in the job... This training and/or related experience shall provide knowledge of and skill... (3) Skill and knowledge required to provide resident care and supervision, including... to communicate with residents. This requirement was not met as evidence by:
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Administrator agreed to submit a written plan on how the facility will operate when short staff and how S2 will not be left alone with residents after fingerprinted and associated.
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Based on observation and interview the Licensee did not comply with the section cited above in have a staff available on premises to communicate with residents and other, which poses an immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet HumpalTELEPHONE: (510) 285-3928
Laura HallTELEPHONE: (510) 622-2024

DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025

LIC809 (FAS) - (06/04)
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