197603652-7-19-2021-31-AS-NGID-C7KT6S-20211007142734

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603652
Report Date: 07/19/2021
Date Signed: 07/19/2021 11:36:43 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/09/2021 and conducted by Evaluator Patrick Shanahan

COMPLAINT CONTROL NUMBER: 31-AS-20210709100024

FACILITY NAME:	AMBASSADOR GARDEN		FACILITY NUMBER:	197603652
ADMINISTRATOR:	SOFI DRUKER		FACILITY TYPE:	740
ADDRESS:	7324 CANBY AVENUE		TELEPHONE:	(818) 705-3404
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	158	CENSUS: 79	DATE:	07/19/2021
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Ana Peciado/ Med Tech		TIME COMPLETED:	11:54 AM

ALLEGATION(S):

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Resident caused harm to another resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Patrick Shanahan, Arrived at the facility at 8:40 am in response to the above mentioned allegation. LPA was greeted by facility staff and explained the reason for the visit.
At 8:50am, LPA began touring the facility and interviewing residents and staff regarding the allegation

At 9:15 am, LPA was able to speak with one of the residents (R1) in question. R1 confirmed that a fight had broke out and that R1 had struck the other resident (R2). After R1 struck R2, R2 stated that R2 was going to stab R1 and retreated to R2's room and came back out with a knife.

Staff who were present at the time of the incident were interviewed at 10 am over the phone. All staff interviewed confirmed that R1 hit R2. R2 stated that R2 was going to R2's room to get a knife to stab R1.
When R2 came out of the room, R2 did have a knife and staff moved R1 out of the way and were able to get the knife from R2.
Continues on Lic 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick Shanahan	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

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 3

Control Number 31-AS-20210709100024

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMBASSADOR GARDEN	FACILITY NUMBER: 197603652
	VISIT DATE: 07/19/2021

NARRATIVE

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All staff and residents interviewed confirmed that R2 did state that R2 was returning to the bedroom to get a knife. Staff interviewed stated that they did not believe R2 was getting a knife and were surprised when R2 came out of the room with a knife.

Staff and residents also confirmed once R2 returned with the knife, staff removed R1 from danger and were able to get the knife from R2. 911 was called and the police did arrived but no charges were pressed by either resident.

Based on information received by staff and residents, this allegation is deemed substantiated at this time. Exit interview conducted, deficiencies cited and report issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick Shanahan	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20210709100024

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMBASSADOR GARDEN	FACILITY NUMBER: 197603652
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/19/2021 Section Cited CCR 87468.1	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in all Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal right: (3) To be free from punishment, humiliation, intimidation, abuse... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Staff immediately separated R1 and R2. R1's room has been changed to the opposite side of the facility. The police were called and reports made. POC corrected prior to visit.
	8 9 10 11 12 13 14	Based on the interviews with staff and residents, the Licensee did not ensure that clients are free from abuse, as R1 struck R2 which posed an immediate health and safety risk to the residents in care.	8 9 10 11 12 13 14
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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.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick Shanahan	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

LIC9099 (FAS) - (06/04)

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