197603652-4-25-2024-31-AS-HRAI-D4NT6S-20240425142736

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603652
Report Date: 04/25/2024
Date Signed: 04/25/2024 02:28:40 PM

Document Has Been Signed on 04/25/2024 02:28 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
WOODLAND HILLS S.RO, 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: 70	DATE:	04/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sofi Druker, Administrator		TIME COMPLETED:	02:45 PM

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At 10:00 AM Licensing Program Analysts (LPAs), Huma Rahimi, and Nicholas Reed, conducted an unannounced annual inspection at the facility mentioned above. LPAs were greeted at the front desk by the staff Ezabella Litmanovich and later met with the Administrator, Sofi Druker, and explained the reason for the visit. Physical tour was conducted with the Administrator and LPAs observed the following:

The facility was last visited on 03/19/2024, for a complaint visit. The facility 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.

Elevator: The facility had one functioning elevator. LPAs observed a posting for the facility’s emergency evacuation routes which was clearly labeled.

Bedrooms: LPAs and Administrator toured vacant and occupied bedrooms on the first and second floor. LPAs observed lamps, nightstands, beds, linens, and private bathrooms with liquid soap, hand towels, and trash cans. Private bathrooms also had grab bars in the showers and around the toilets.

Bathrooms: The facility currently has one public restroom on the first floor and two public restrooms on the second floor. The bathroom was sanitary with liquid soap, paper towels, handwashing instruction sign, and a trash can with a tight-fitting lid. At 10:20 AM, LPAs measured the hot water temperature on the first floor to be 106.8F and 111.7F on the second floor.

Outside of the bathroom was the facility’s telephone. It is a payphone, but quarters are available free of charge at the front desk. The facility has an additional telephone on the second floor for incoming resident calls.

Continue on LIC 809C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMBASSADOR GARDEN	FACILITY NUMBER: 197603652
	VISIT DATE: 04/25/2024

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Common Areas: All floors, walls, and ceilings were clean. Furniture in the dining room, lounges, living room, and activity room were clean and in good repair. Hand sanitizer was readily available. Facility posted the most recent Community Care Licensing (CCL) Provider Information Notice at the front desk, along with recent CCL reports, an activity schedule, resident rights poster, and a confidential complaint hotline. At 10:35 AM LPAs measured the room temperature to be 73F.

Outdoor Space: LPAs and Administrator toured the outside space. One gazebo was designated for resident smoking, had ashtrays, and were at least 20 feet from buildings. LPAs observed two (2) locked storage sheds which contained gardening tools in parking lot area. Sufficient space was available for activities.

LPAs walked on the south side of the facility’s exterior and tested an exit door which was unlocked from the inside. LPAs observed an electronic gate on the north side of the facility’s exterior which led to the employee parking lot.

Laundry: In the back parking lot, LPAs observed a laundry room with two (2) washers and two (2) dryers. Detergents were locked in a closet.

Medication Room: LPAs observed a locked Medication Room and met with a Med Tech who supervised and dispensed medication. Med Tech informed LPAs that all residents have at least a 30 day supply of medication.

Storage: LPAs observed a storage room with sufficient emergency food and water supplies. LPAs also observed a locked maintenance room with cleaning supplies. LPAs observed an additional, locked storage room on the second floor designated for PPE.

Kitchen: LPAs observed menus outside of the kitchen and dining room. Menus applied to typical and diabetic diets. The kitchen floors and surfaces were clean, and all food was sealed and labeled. Cleaning supplies remained by the dishwashing area and were not stored with food. The dining room contained tables with designated seating with labels for residents with special diets.

Continue on LIC 809C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: AMBASSADOR GARDEN	FACILITY NUMBER: 197603652
	VISIT DATE: 04/25/2024

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Fire Safety: LPAs observed that the facility has fifteen (15) fire extinguishers, and all were fully charged and last serviced on 11/29/2023. LPAs observed all required postings by the front desk of the facility. The facility has fire sprinklers throughout the inside of the facility, resident bedrooms, hallways, dining room, and outdoors as well. At 12:45 p.m. LPAs reviewed the most recent fire safety report from the Los Angeles Fire Department conducted on 12/04/2023. All systems were functional and passed inspection.

At 1:00 p.m. LPAs tested the call system in Room #207 to be functional. Staff responded to the call within thirty (30) seconds.

LPAs observed that one screen door was not in good repair. LPAs also observed that the fire door glass was cracked.

Between 1:00 PM to 2:30 PM, LPAs reviewed records of seven (7) resident and four (4) staff. Resident and staff records appeared to be complete and updated.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC809 (FAS) - (06/04)

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