197603652-12-7-2022-31-AS-NMAN-CN9TUL-20230120140231

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603652
Report Date: 12/07/2022
Date Signed: 12/07/2022 01:17:40 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
12/01/2022 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20221201090344

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:	12/07/2022
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Sofi Druker		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff hit resident in care.
Staff confiscated resident's belongings.

INVESTIGATION FINDINGS:

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At 9:55 a.m. on 12/07/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later Administrator and disclosed the reason for the visit.

At approximately 10:15 a.m. LPA conducted a records review. From 10:50 a.m. to 11:30 a.m. LPA interviewed the Administrator, Staff #1 (S1), and Staff #2 (S2). LPA and Administrator toured the facility, resident rooms, and the outside areas. No immediate health and safety concerns were observed. At 11:35 a.m. the Administrator shared pertinent photographs with LPA.

Regarding the allegation above, it was alleged staff hit Resident #1 (R1). From interviews, no staff were aware of instances of hitting or abuse. S1 stated R1 was normally quiet, but R1 sexually and verbally harassed staff after becoming intoxicated. The Administrator noted R1’s history of alcohol abuse and knew R1 did not want to return to the facility. (continued on LIC 9099-C page)

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20221201090344

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: 12/07/2022

NARRATIVE

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From record review, the social worker at the hospital noted R1’s intoxication as R1 alleged the staff abuse. Based on record review, interviews, and observations, 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.

Regarding the allegation above, it was alleged staff took R1’s belongings and would not release them. From interviews, the Administrator and staff did not know of any requests for R1’s belongings to be released. The Administrator also noted R1’s room had a cockroach infestation from spoiled meat in their refrigerator. S2 confirmed the cockroach problem. From record review, a pest control company serviced the room on 11/28/2022 and removed the refrigerator. R1’s responsible party was notified and said to remove all spoiled food. S1 stated R1 was admitted to the hospital on 11/29/22. LPA observed all belongings listed on R1’s inventory form (LIC 621) were still present at the facility. Based on record review, interviews, and observations, 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: 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

LIC9099 (FAS) - (06/04)

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