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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601562
Report Date: 05/19/2023
Date Signed: 05/19/2023 04:04:21 PM

Document Has Been Signed on 05/19/2023 04:04 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
GREATER LA AC/SC, 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:
05/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Eboni Campbell, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted the required annual inspection. LPA was allowed entry by Maydia Jimenez/Direct Support Professional(DSP). LPA explained the purpose of today's visit. LPA spoke with The Administrator, Ebony Campbell on the phone. Administrator was not present at the facility and scheduled to arrive at 2pm. Gloria Fletcher, Direct Support Professional(DSP) assisted LPA with the inspection. The facility is licensed to serve three(3) Adults 18 Years and above. Three (3) may be non-ambulatory. Current census is (2), non ambulatory and non verbal. All clients residing at this facility receive case management services provided by South Central LA Regional Center (SCLARC). At 3:50pm, the Administrator, Eboni Campbell arrived just in time to discuss and sign the reports.
LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies. Facility does not have an Infection Control Plan on file. Staff are adhering to infection control requirements.
Physical Plant & Environment Safety: This facility consists of (3) bedrooms, (2) full bathrooms, living/activity room, kitchen, dining area, and detached garage. Smoke alarms were tested and operable. Fire extinguisher appeared to be full and was last serviced on 12/08/2022. Carbon monoxide tested and operable. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. There are no firearms or weapons stored at the facility. Hot water supply measured 118.3* in the kitchen, 116.5* in bathroom #1, and 116.8* in bathroom #2.
Operational Requirements: The fire clearance is approved for (3) non ambulatory clients. Last Fire Drill was conducted on 10/19/2022. Fire and Earthquake drill
Staffing: There is sufficient staffing at the facility. The Administrator stated that she has a valid Administrator certificate but due for renewal this year. Administrator will email LPA the valid Administrator certificate. LPA was not able to review the Administrator's file due to inaccessibility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

***Refer to LIC 809C for the continuation of this report***
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
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 05/19/2023 04:04 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/19/2023 at 02:18 PM
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: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80077.3(a)
Care for Clients who Lack Hazard Awareness or Impluse Control
(a) If a client requires protective supervision because of running/wandering away, supervision may be enhanced by fencing yards, using self-closing latches and gates, and installing operational bells, buzzers, or other auditory devices on exterior doors to alert staff when the door is opened. The fencing and devices must not substitute for appropriate staffing.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in that the exit door leading to a fenced backyard in bedroom #2 did not have an auditory device which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2023
Plan of Correction
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Administrator will submit photos of the exit door in bedroom #2 to show that a door buzzer/auditory device has been installed to CCL or LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


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Document Has Been Signed on 05/19/2023 04:04 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/19/2023 at 02:18 PM
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: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the Administrator did not comply with the section cited above in that the facility did not have an Infection Control Plan which posed a potential health, safety or personal rights risk to clients in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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The Administrator will submit an updated infection Control Plan to CCL/LPA. Additionally, the Administrator will review the PINs related to the plan and submit a signed statement that the PINs has been read, reviewed and understood on or before the POC due date.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in which the faucet in bathroom #2 was not installed properly, the base was loose and moving. Additionally, the bathroom sink was draining very slowly and water not going down right away which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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The Administrator will submit photos and receipts or service order to show that the faucet and sink in bathroom #2 have been fixed to CCLD/LPA 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/19/2023 04:04 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/19/2023 at 02:18 PM
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: 05/19/2023

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 interview and record review, the Administrator did not comply with the section cited above in which 1 out of 3 staff files checked did not have a current First Aid/CPR training. Last training completed was 2/11/2021 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Administrator will ensure that all direct staff have the current First Aid/CPR training completed and filed. Submit a copy of the First Aid/CPR training for DSP Melanie Morales.
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the Administrator did not comply with the section cited above in which the non perishable items stored in the facility are insufficient and not enough for 7 days which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2023
Plan of Correction
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Administrator will submit photos and receipts showing additional food items/non perishable items kept in the facility to CCLD/LPA 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


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Document Has Been Signed on 05/19/2023 04:04 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/19/2023 at 02:49 PM
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: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(c)(e)(1)
80066(c)(e)(1) Personnel Records (c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours...(e) All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review. (1) The licensee shall be permitted to retain such records in a central administrative location provided that they are readily available to the licensing agency at the facility site as specified in Section 80066(c).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the Administrator did not comply with the section cited above in which some of the files were not accessible to staff present during the facility. Administrator has the key to the locked files and navailable to staff which poses/posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2023
Plan of Correction
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Licensee shall have all the required forms immediately available to Licensing agency personnel. LPA was not able to review all the pertinent files because the staff working at the facility did not have access to it and Administrator who has the key to the locked filing cabinet was not present. Administrator will submit the plan in writing indicating how and where to make files accessible to the licensing agency to CCL/LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: AMBIRIA HOMES II
FACILITY NUMBER: 198601562
VISIT DATE: 05/19/2023
NARRATIVE
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Personnel Records-Training: Some Staff files are maintained at the facility. LPA reviewed staff files for S1, S2 and S3. Staff have sufficient on-going training that meets the annual requirement. Staff have their Health Screening on file. One of the staff, S3 did not have a current First Aid/CPR Training. S3 file shows she took the First Aid/CPR training on 2/11/2021. The latest fire drill on file was Oct. 19, 2022.
Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. Per Administrator, none of the clients have their own personal cell phones. Per Administrator, none of the clients have their own tablet, but a generic tablet is provided by the Adult Day Program.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C2. Some of the client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Personal Property and Clients Personal Rights observed. Food Service: There are sufficient food supplies of 2-day perishable, but insufficient supplies of non-perishable items. The food is properly stored in the refrigerator. There is one client with a modified diet residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas. Plates, cups and utensils are kept cleaned and stored properly.
Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for C1 through C2. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed. No discrepancies noted.
Incidental Medical Services: Per Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: LPA did not see the file for a complete Emergency Disaster and Mass Casualty Plan.
Emergency Intervention: Not-Applicable.

Deficiencies cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided
to Eboni Campbell, Administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 05/19/2023 04:04 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/19/2023 at 03:28 PM
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: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(f)
Furniture, Fixtures, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents.

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in that a big plastic trash bin without a cover/lid was placed inside the bathtub in bathroom #1 which was open and full of waste which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2023
Plan of Correction
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The Administrator will replace the trash in bathroom #1 with a cover/lid and will ensure that staff clean and dispose the waste frequently. Administrator will submit photos and receipts to CCL/LPA by POC due date.
Type B
Section Cited
CCR
80023(d)(2)
80023 (d) (2) Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.
(2) The drills shall be documented and the documentation maintained in the facility for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the Administrator did not comply with the section cited above in which the facility did not conduct or kept a current fire/earthquake drill log. The last fire drill conducted was October 2022, based on the facility's file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2023
Plan of Correction
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Administrator will ensure that fire drills are conducted at least once every six months on each shift and shall include, at a minimum, all direct care staff. Administrator will conduct a fire drill and document it and include all staff named during each shift. Submit a copy of the fire drill log to CCL/LPA 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


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