198601562-4-25-2022-28-AS-JBAE-CDTQAH-20220425115957

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601562
Report Date: 04/25/2022
Date Signed: 04/25/2022 12:00:48 PM

Document Has Been Signed on 04/25/2022 12:00 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 II		FACILITY NUMBER:	198601562
ADMINISTRATOR:	SHAWNTRIS LEAKE		FACILITY TYPE:	735
ADDRESS:	8141 VICTORIA AVE.		TELEPHONE:	(323) 567-2842
CITY:	SOUTH GATE	STATE: CA	ZIP CODE:	90280
CAPACITY: 3		CENSUS: 2	DATE:	04/25/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	Shawntris Leake, Administrator		TIME COMPLETED:	12:10 PM

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Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced annual inspection at the facility with focus on the infection control domain, food, and medication review. LPA Baptiste met with Josue Pompalopez, Day Program manager and explained the reason for the visit.

Facility is licensed to serve 3 Adults 18 Years and above, which 3 may be non- ambulatory. At the time of inspection facility census is 2. Facility is located in a residential neighborhood, single story house with a living room, dining room, kitchen w/ office area, 3 bedrooms, 2 bathrooms(1 for staff), laundry room, and garage. There are 2 clients residing in the home. All of the clients have PICA, and the staff to client ratio is 1:1 in home and 2:1 in the community.

LPA and Day Program manger toured the facility together and observed the kitchen with 2 day supply of perishables and 7 day supply of non perishables. The bedrooms have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. LPA observed bedroom #2 chair cushion in disrepair. Bedroom #3 walls are scratch and worn out. Passageways and exits are free of obstruction. The front and backyard are well maintained. The resident bathrooms are clean, and showers have non-skid materials.The hot water temperature measured at 119.7 degrees F.

Report continued on 809c

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 II	FACILITY NUMBER: 198601562
	VISIT DATE: 04/25/2022

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The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors located throughout the facility, tested and operational. Carbon monoxide detector was also observed, tested and operational. Fire extingusher observed fully charged and in the kitchen. LPA observed a sufficient supply of PPE in garage.

LPA was not able to review staff due to facility staff not having access. LPA reviewed medication and medication logs complete and given as ordered. The last fire drill was conducted on 11/2021. Administrators Certificate for Kristen Wooten #6035400735 expires on 05/18/2023.

The following deficiencies were cited per California Code of Regulations, Title 22 on the LIC 809D. Exit interview conducted with Day Program manager and House manager Eboni Campbell (Phone). A copy of this report and appeal rights given.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/25/2022 12:00 PM - It Cannot Be Edited

Created By: Jewel Baptiste On 04/25/2022 at 11:00 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 II	FACILITY NUMBER: 198601562
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Buildings and Grounds The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in which client chair cushion in bedroom #2 need to be replaced and the walls in bedroom #3 need to be painted, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/25/2022
	Plan of Correction
1 2 3 4	Licensee shall submit picture proof or receipts of chair and painted walls by POC date( 5/25/2022) to LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Lisa Hicks

LICENSING EVALUATOR NAME:

Jewel Baptiste

LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

LIC809 (FAS) - (06/04)

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