197603652-11-30-2022-31-AS-MVAO-CM3T7H-20221213132846

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603652
Report Date: 11/30/2022
Date Signed: 11/30/2022 03:39:38 PM

Unsubstantiated

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
11/29/2022 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20221129091305

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: 72	DATE:	11/30/2022
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Sofi Druker		TIME COMPLETED:	03:47 PM

ALLEGATION(S):

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Facility is in disrepair (broken elevator).

INVESTIGATION FINDINGS:

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At 2:15 p.m. on 11/30/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out. No immediate health and safety concerns were observed.

Regarding the allegation above, it was alleged the facility elevator is broken, and the facility has not accommodated residents during the maintenance. At 2:20 p.m. LPA inspected the elevator and elevator control room. At 2:30 p.m. LPA interviewed the Administrator. At 2:38 p.m. LPA conducted a record review. From observations, the facility posted signs on the elevator stating it was inoperable and estimated to be repaired by 12/05/22. In the elevator control room, LPA observed a new, large barrel of oil, two packages with new parts, and a new control box. From interviews, the Administrator stated the elevator is old and therefore has been difficult to repair. The facility hired a company in June to fix the elevator, and it worked for a month and a half. The elevator broke again in September, and the facility hired a new company to completely renovate the elevator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20221129091305

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: 11/30/2022

NARRATIVE

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Since then, the Administrator has called the elevator company every day for updates. Administrator stated the company was at the facility just ten minutes before LPA arrived to deliver the large barrel of oil. From record review, the facility reported the elevator’s maintenance on an LIC 624 form on 07/09/2022. The facility accommodated residents by offering tray service to bring food to residents 3 times each day. Med techs brought medication to residents on the second floor, and the facility offered to temporarily move residents to the first floor if requested. The Administrator called LPA at 3:27 p.m. on 07/19/2022 to report that elevator parts had been found, but all 5 technicians from the company were sick with COVID. LPA observed a check written to the new elevator repair company from 09/14/2022 and the “Elevator Modernization Contract” with the new elevator repair company, signed on 10/14/2022. LPA also observed the Dining Room Absence Log which showed room numbers, times, and meals to be brought to residents. An email sent on 11/08/2022 cited supply chain challenges as a reason for delays in parts and showed an estimated date of completion as 01/03/2023. Based on observations, interviews, and record review, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

LIC9099 (FAS) - (06/04)

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