197603652-1-10-2023-31-AS-NRED-CMXR6G-20230110114443

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603652
Report Date: 01/10/2023
Date Signed: 01/10/2023 11:44:58 AM

Document Has Been Signed on 01/10/2023 11:44 AM - 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 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:	01/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Sofi Druker		TIME COMPLETED:	11:54 AM

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At approximately 10:05 a.m. on 01/10/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with the Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out.

The facility was last visited on 12/20/2022 for a complaint visit. It is a two story building with private and shared bedrooms, private bathrooms, kitchen, dining room, recreation rooms, common areas, patios, and outdoor areas. It has an approved fire clearance for 89 ambulatory residents and 69 non-ambulatory residents on the first floor only. Approved hospice waivers for 3.

Upon entry, LPA observed signs for the facility’s masking and visitation policies. COVID precautions were posted throughout the building. Other postings included the Ombudsman contacts, emergency disaster plan, facility license, facility sketch, grievance procedure, rights of resident councils, non-discrimination notice, theft and loss policy, daily menu, and activity calendar. The confidential complaint sign had been ripped off, so LPA instructed the Administrator to repost the notice.

LPA was screened for infectious disease upon entry. The screening station contained a digital thermometer, visitor log, hand sanitizer, and N95 masks. All staff were observed wearing N95 masks. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At approximately 10:30 a.m. LPA observed residents participating in a staff-led exercise program in the main living room. LPA also observed outside contractors repairing A/C units. The facility elevator was operational, and staff and LPA used it to access the second floor. Fire extinguishers were posted at hallway corners. At 10:32 a.m. LPA observed a fully charged fire extinguisher on the second floor. It was last service on 11/12/2022. Room 212 was inspected. It contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. At 10:43 a.m. the water temperature from the bathroom faucet was measured at 112.1 degrees Fahrenheit. The bathroom contained liquid soap, trash can, and grab bars near the toilet and shower. At 10:48 a.m. staff tested the smoke detector to be functional. At 10:52 a.m. staff tested the carbon monoxide detector near the dining room to be functional.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/10/2023

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LPA observed an adequate supply of perishable and non-perishable food in the kitchen. Surfaces were sanitary. Cleaning solutions were stored away from food. Sharps and cleaning solutions were attended to by staff and inaccessible to residents. The maintenance room, nurse room, and medication room were all locked. LPA observed a fully stocked first aid kit in the medication room. The back patio contained a designated smoking area. Emergency exits paths were free of hazards and unlocked. A covered seating area contained furniture in good repair. At 11:35 a.m. LPA measured the room temperature to be 75.4 degrees Fahrenheit.

The Administrator notified LPA that although the elevator is currently functional, it will need to be shut down soon for further maintenance. Maintenance is scheduled for February 2023 and a city inspection will follow. LPA advised the Administrator to inform all residents of the scheduled maintenance once exact timeframes are known.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued.

Exit interview conducted. 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: 01/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

LIC809 (FAS) - (06/04)

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