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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200582
Report Date: 11/12/2024
Date Signed: 11/12/2024 04:53:14 PM

Document Has Been Signed on 11/12/2024 04:53 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: 4DATE:
11/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Bienvenido Espina, CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
NARRATIVE
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On 11/12/2024 at 09:50am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. LPA met with Administrator, Bienvenido Espina, Caregiver, and explained the purpose of the visit. LPA spoke with Administrator, Raufat Ikharo, via telephone.

LPA toured the facility with including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of four (4) bedrooms and three and one-half (3 1/2) bathrooms. Swimming pool in back yard is surround and locked with metal gate. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was not working. Residents’ bathrooms are equipped with grab bars.

Carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 9/3/2024. First aid kit was observed to be complete.

LPA reviewed four (4) staff files. Three (3) of four (4) were incomplete. LPA reviewed four (4) resident's files and all were incomplete.

Continued on LIC809.
Harpreet HumpalTELEPHONE: (510) 285-3928
Laura HallTELEPHONE: (510) 622-2024
DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 13
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
VISIT DATE: 11/12/2024
NARRATIVE
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Continued from LIC809.

LPA observed the following deficiencies:
  • At 9:45am, LPA observed trash located on left-side of facility which included a clothes hamper, chandelier, card board boxes, filled garbage bags, a chair, and other items.
  • At 10:05am, LPA observed two (2) tubes of ointment on R1's chest of drawers.
  • At 10:05am, LPA observed comet, glass cleaner, and stain/order remover sitting on bathroom counter in master bathroom.
  • At 10:10am, LPA observed a slide bolt lock on exit door leading to back yard.
  • At 10:10am, LPA observed the door leading to the back yard was broken. Door would not stay closed without the bolt lock.
  • At 10:15am, LPA observed unlocked medicine cabinet in kitchen. Cabinet had pad lock but it was unlocked.
  • At 10:17am, LPA observed patio screen off in den area.
  • At 10:18am, LPA observed sticky trap sitting on kitchen counter with dead insects. LPA also observed several traps around the kitchen.
  • At 10:20am, LPA observed Pine-Sol and Fabuloso in unlocked kitchen cabinet underneath sink.
  • At 10:52am, LPA observed unlocked cabinet full of disinfectants and cleaning supplies in laundry area.

LPA requested the following documents to be submitted to CCLD by 11/19/2024.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan
  • Liability Insurance


Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 13
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
VISIT DATE: 11/12/2024
NARRATIVE
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Continued from LIC809C.
  • At 10:55am, LPA observed facility did not have a 7-day supply of non-perishables and 2-day of perishables.
  • At 11:00am, LPA observed there was not any hot water coming out the faucet in the shared bathroom.
  • At 11:30am, LPA observed during record review three (3) of four (4) resident files were missing the admission agreement. None had an appraisal needs and service plan or consent for medical treatment.
  • At 11:35am, LPA observed R1 and R3 glucose was being checked by staff.
  • At 11:40am, LPA observed during record review facility did not have a hospice care plan for R4.
  • At 11:45am, LPA observed during record review facility did not have a health care plan for R2.
  • At 11:55am, LPA observed during record review facility did not have a current and accurate medication list for the residents.
  • At 12:00pm, LPA observed during record review two (2) of four (4) staff was missing first aid and one (1) staff was missing the health screening.
  • At 12:30pm, LPA observed during record review that facility is not conducting fire drills.
  • At 1:30pm, LPA observed during record review that facility had not requested an exception for pressure injury.

*An immediate $500.00 civil penalty will be assessed on today's date for fire safety*

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due date, and any repeat violations within 12-month period may result in civil penalties.



Exit interview conducted. A copy of appeal rights and this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
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: AMBASSADOR CARE HOME
FACILITY NUMBER: 079200582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 in having cleaners and disinfectants inaccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
1
2
3
4
Caregiver immediately removed items from master bathroom, and locked cabinet in laundry room and cabinet underneath kitchen sink. Deficiency was cleared during visit.
Section Cited
Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure sores (dermal ulcers).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in requesting an exception for a prohibited health condition which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
1
2
3
4
Administrator agreed to request an exception for R2 prohibited health condition from CCLD by POC date.
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: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024

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: AMBASSADOR CARE HOME
FACILITY NUMBER: 079200582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 in patio screen in den in repair, exit door to back yard in repair, refrigerator and freezer sanitary which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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2
3
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Administrator agreed to repair door, screen, clean refrigerator ,freezer, and submit photos to CCLD by POC date.
Section Cited
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 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in having hot water in shared bathroom's faucet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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2
3
4
Administrator agreed to have hot water coming from shared bathroom's faucet and submit photo showing temperature while water is running to CCLD by POC date.
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: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024

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: AMBASSADOR CARE HOME
FACILITY NUMBER: 079200582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 in keeping passageway on left side of facility outside free of obstruction which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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2
3
4
Administrator agreed to have all items removed and submit a photo to CCLD by POC date.
Section Cited
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having all staff files complete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
1
2
3
4
Administrator agreed to complete all staff files and submit self-certification that they were completed to CCLD by POC date.
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: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024

LIC809 (FAS) - (06/04)
Page: 6 of 13
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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: AMBASSADOR CARE HOME
FACILITY NUMBER: 079200582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having kitchen area clean of insects which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
1
2
3
4
Administrator agreed to submit invoice from exterminator stating what services the facility have to CCLD by POC date.
Section Cited
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in conducting quarterly fire drills which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
1
2
3
4
Administrator agreed to conduct a fire drill and submit document to CCLD by POC date.
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: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024

LIC809 (FAS) - (06/04)
Page: 7 of 13
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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: AMBASSADOR CARE HOME
FACILITY NUMBER: 079200582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Allowable Health Conditions and the Use of Home Health Agencies
(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having a home health care plan for R2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
1
2
3
4
Administrator agreed to obtain care plan and submit copy to CCLD by POC date.
Section Cited
Diabetes
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in retaining residents that are able to perform his/her own glucose testing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
1
2
3
4
Administrator agreed to implement a plan for R1 and R2 to conduct own glucose testing or have a skilled professional conduct testing and submit to CCLD by POC date.
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: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024

LIC809 (FAS) - (06/04)
Page: 8 of 13
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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: AMBASSADOR CARE HOME
FACILITY NUMBER: 079200582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having a hospice care plan maintained at the facility for R4 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
1
2
3
4
Administrator agreed to obtain a hospice care plan for R4 and submit a copy to CCLD by POC date.
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.
Harpreet HumpalTELEPHONE: (510) 285-3928
Laura HallTELEPHONE: (510) 622-2024

DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024

LIC809 (FAS) - (06/04)
Page: 9 of 13
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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: AMBASSADOR CARE HOME
FACILITY NUMBER: 079200582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates:

(6) Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents.

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 in having a bolt lock on door leading to back yard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
1
2
3
4
Administrator agreed to remove lock and submit photo to CCLD by POC date
Section Cited
(h) The following requirements shall apply to medications which are centrally stored:

(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 in having medication inaccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
1
2
3
4
Caregiver removed ointment and locked medicine cabinet located in kitchen immediately. Deficiency was cleared during visit.
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: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024

LIC809 (FAS) - (06/04)
Page: 11 of 13
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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: AMBASSADOR CARE HOME
FACILITY NUMBER: 079200582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
(b) The following food service requirements shall apply:

(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

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 in having a 7-day supply of non-perishables and 2-day perishable foods which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
1
2
3
4
Administrator agreed to purchase food and submit photos of food and receipts to CCLD by POC date.
Section Cited
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having all resident records complete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
1
2
3
4
Administrator agreed to complete all resident records and submit a self-certification to CCLD that records are complete to by POC date.
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: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024

LIC809 (FAS) - (06/04)
Page: 12 of 13
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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: AMBASSADOR CARE HOME
FACILITY NUMBER: 079200582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having and accurate record for all medication maintained in each residents file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2024
Plan of Correction
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Administrator will complete a record for each residents' medication, maintain it in the file and submit a self-certification that it has been completed to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024

LIC809 (FAS) - (06/04)
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