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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603652
Report Date: 12/07/2022
Date Signed: 12/07/2022 01:19:33 PM


Document Has Been Signed on 12/07/2022 01:19 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:AMBASSADOR GARDENFACILITY NUMBER:
197603652
ADMINISTRATOR:SOFI DRUKERFACILITY TYPE:
740
ADDRESS:7324 CANBY AVENUETELEPHONE:
(818) 705-3404
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:158CENSUS: 72DATE:
12/07/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Sofi DrukerTIME COMPLETED:
12:55 PM
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During the complaint investigation for complaint # 31-AS-20221201090344, Administrator Sofi Druker requested guidance from Licensing Program Analyst (LPA) Nicholas Reed. At 11:45 a.m. on 12/7/22, LPA initiated a case management visit.

From 11:45 a.m. to 12:40 p.m. LPA interviewed the Administrator Sofi Druker and Resident #1 (R1). LPA attempted to assist the maintenance of a broken call system pull cord in R1’s bathroom. Multiple attempts to fix the call system were made. In respecting the personal rights of R1, the facility will wait to fix the call system until R1 leaves the facility or requests maintenance. The call system pull cord in the main part of R1’s room was functional.

Exit interview conducted. Copy of Report provided.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022
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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