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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601561
Report Date: 03/21/2023
Date Signed: 03/21/2023 11:10:04 AM

Document Has Been Signed on 03/21/2023 11:10 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:AMBIRIA HOMES IFACILITY NUMBER:
198601561
ADMINISTRATOR:CARMEN VARGASFACILITY TYPE:
735
ADDRESS:6424 SHERMAN WAYTELEPHONE:
(323) 771-6800
CITY:BELLSTATE: CAZIP CODE:
90201
CAPACITY: 4CENSUS: 2DATE:
03/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:House Manager Horace EvansTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Glenn Trueman made a visit to the facility and was greeted by House Manager Horace Evans and explained the reason for the visit.
The purpose of the visit is to conduct the required 2023 annual inspection.
Currently there are 2 clients.
Annual Inspection includes the following Domains:
Infection Control, Physical Plant and Environmental Safety, Operational Requirements, Staffing, Personnel Records- Training, Client Rights Information, Client rights- Incident Reports, Food Service, Health Related services, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention.
Tour of the facility was conducted and the following was observed;
There are 3 Client Bedrooms which have the required furniture such as bedframes, dressers, lamps and chairs.
Beds have the required linen and the linen is in good condition.
There is 1 Client bathroom. The bathrooms are clean and have the required hygiene items. The hot water temperature was within the required 105 - 120 degrees.
The facility temperature at the time of the visit was comfortable.
There is sufficient lighting throughout the facility. There are smoke detectors located throughout the facility. There is a carbon monoxide detector. The kitchen was inspected. There is sufficient perishable and non-perishable food. The food was also stored properly. Kitchen appliances are clean and are operating properly. The front and backyard are well maintained. There is no pool or other large bodies of water.
Staff was interviewed.
Infection Control Plan has not been submitted.
Advisory Notice issued. Plan due by. 03/28/2023.
1 staff did not have a current 1st Aid with expiration date of 10/17/2022.
Facility did not have an emergency and disaster plan on file.
Deficiencies cited on 809 D. Exit interview conducted.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2023
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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Document Has Been Signed on 03/21/2023 11:10 AM - It Cannot Be Edited


Created By: Glenn Trueman On 03/21/2023 at 10:29 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AMBIRIA HOMES I
FACILITY NUMBER: 198601561

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above with 1 staff having expired 1st Aid 10/17/22 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2023
Plan of Correction
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Licensee to submit current 1st Aid by POC due date.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above with facility not having a emergency and disaster plan on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2023
Plan of Correction
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Licensee to submit emergency and disaster plan by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Glenn Trueman
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023


LIC809 (FAS) - (06/04)
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