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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601562
Report Date: 01/21/2022
Date Signed: 01/21/2022 02:00:39 PM

Document Has Been Signed on 01/21/2022 02:00 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:AMBIRIA HOMES IIFACILITY NUMBER:
198601562
ADMINISTRATOR:SHAWNTRIS LEAKEFACILITY TYPE:
735
ADDRESS:8141 VICTORIA AVE.TELEPHONE:
(323) 567-2842
CITY:SOUTH GATESTATE: CAZIP CODE:
90280
CAPACITY: 3CENSUS: 2DATE:
01/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Alfreda Garner, StaffTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced initial case management visit regarding the death of client #1 (C1) which occurred on 1/8/2022. LPA met with staff, Alfreda Garner and spoke with Administrator, Kristen Wooten Newman over the phone and explained the reason of the visit.
According to the incident report dated 1/10/22, C1 passed away on 1/8/22 in the hospital. The suspected cause of death is Cardio-Pulmonary Arrest. C1 had Covid positive and finished with quarantine.

During today's visit, administrator was interviewed, C1's file was reviewed and obtained the following:
· Staff roster and Client roster
· Client #1 (C1) facesheet dated 3/18/14
· Unusual incident reports, dated 1/10/22
· C1's annual report dated 10/21/19
· C1's nurse visit record dated 12/30/21
· C1's nurse progress notes dated 8/5/21
· C1's record of Medical visit dated 4/12/21
· C1's medication record (MAR) dated Dec 2021 and Jan 2022
· C1's physician's Report dated 5/18/21

Requested the following documents:
· C1's annual report / IPP - year of 2021. Due 1/26/22

Administrator stated she may get the death certificate and coroner report from C1's family when available. Exit interview was conducted and a copy of LIC 809 Report was provided to staff
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2022
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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