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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200582
Report Date: 07/02/2025
Date Signed: 07/02/2025 02:35:00 PM

Substantiated


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
06/24/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250624091855
FACILITY NAME:AMBASSADOR CARE HOMEFACILITY NUMBER:
079200582
ADMINISTRATOR:IKHARO-UMARU, RAUFATFACILITY TYPE:
740
ADDRESS:145 BEEDE WAYTELEPHONE:
(510) 812-2188
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 5DATE:
07/02/2025
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Raufat Ikharo-Umaru, AdministratorTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Staff failed to observe change in resident's condition
Staff failed to meet resident's medical needs in a timely manner
INVESTIGATION FINDINGS:
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On 07/02/25 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (ADM, S1), gathered information and delivered investigation findings to ADM. LPA explained the purpose of the visit with staff.

During investigation, LPA conducted interviews with reporting party (RP), staff (ADM, S1), resident (R1), authorized representative (POA) and obtained the following documents from administrator – Personnel record (LIC500), Residents roster, admission agreement, physician’s report, needs & services plan, centrally stored medication logs, medication administration records, after visit summary reports, incident reports.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
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 4
Control Number 15-AS-20250624091855
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: 07/02/2025
NARRATIVE
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Allegation: Staff failed to observe change in resident’s condition
Investigation Finding: Substantiated
During investigation, LPA conducted interviews with, reporting party (RP), authorized representative (POA) resident (R1), staff (ADM) and reviewed resident (R1) documents. Staff (ADM, S1) confirmed with LPA that on 06/23/25 S1 spoke with ADM on the phone around 11AM who requested him to check on R1. S1 stated he checked on R1 and did not notice any change in condition. ADM also spoke with R1 on the phone and told POA that he sounded fine. POA stated she called R1 again and observed R1 have slurred speech and that his face was drooping. She immediately called 911 so that he can be taken to the hospital right away. R1 was taken to the hospital by paramedics and diagnosed with a stroke and urinary tract infection. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff failed to observe change in resident’s condition was found to be substantiated.

Allegation: Staff failed to meet resident’s medical needs in a timely manner
Investigation Finding: Substantiated
During investigation, LPA conducted interviews with, reporting party (RP), authorized representative (POA) resident (R1), staff (ADM) and reviewed resident (R1) documents. LPA interviewed RP and POA who stated that on 06/23/25 while on a Facetime call, POA observed R1 have slurred speech and that his face was drooping. POA immediately called ADM to have staff check on R1. ADM stated that staff checked on R1 around 11:15AM and that he sounded “fine”. POA stated staff did not call 911. R1 called POA again and requested for 911 because staff was not doing anything. R1 was picked up by paramedics on 06/23/25 and was admitted at the hospital with a diagnosis of a stroke and UTI. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff failed to meet resident’s medical need in a timely manner was found to be substantiated.

Continued on next page, LIC 9099-C pg2
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20250624091855
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: 07/02/2025
NARRATIVE
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Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20250624091855
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2025
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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By POC due date, ADM agrees to complete and submit to CCLD in-service staff retraining by a certified vendor on observation of resident in compliance with Section 87466.
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This requirement was not met as evidenced by staff failed to observe resident’s change in condition which posed a potential health & safety risk to resident in care.
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Type B
07/25/2025
Section Cited
CCR
87463(e)
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The licensee shall immediately, or as soon as reasonably possible, bring any significant change in condition, as defined in Section 87101, Definitions, to the attention of the appropriate licensed medical professional and if applicable, other specialized care provider…
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By POC due date, ADM agrees to complete and submit to CCLD in-service staff retraining by a certified vendor on proper resident reappraisal in compliance with Section 87463(e)
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This requirement was not met as evidenced by staff failed to meet resident’s medical needs in a timely manner which posed a potential health & safety risk to resident 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4