198601562-3-5-2024-28-AS-THEA-D343DD-20240305170923

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601562
Report Date: 02/29/2024
Date Signed: 03/05/2024 05:09:44 PM

Document Has Been Signed on 03/05/2024 05:09 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 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: 4		CENSUS: 2	DATE:	02/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:22 PM
MET WITH:	Eboni Campbell - Administrator		TIME COMPLETED:	05:15 PM

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Licensing Program Analyst (LPAs) Tena Herrera and Daniel Konishi conducted the required unannounced annual inspection. LPAs met with Administrator Eboni Campbell and explained the reason for the visit. The facility is licensed to serve 2 Ambulatory and 2 Non-Ambulatory, Developmentally Disabled Adults ages 18-59. Facility currently has 2 Non-Ambulatory clients serviced by South Central Los Angeles Regional Center.

The facility is a single-story home located in a residential area in Bellflower, Ca. A tour of the facility includes: living room, dining area, kitchen, 3 client bedrooms, 1 client bathroom, 1 staff bathroom, detached garage, front yard and back yard.

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 gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the client bathroom and was outside the required range of 105-120 degrees F, measuring at 101.8 Degrees F (details will be documented in the 809-D). All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet near the laundry area and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged.
(Continued on the LIC809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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 03/05/2024 05:09 PM - It Cannot Be Edited

Created By: Tena Herrera On 03/05/2024 at 04:05 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: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). 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 as LPAs tested water temperature in client bathroom and it measured at 101.8 degrees F, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2024
	Plan of Correction
1 2 3 4	Administrator adjusted water temperature during visit to warm up the water, prior to leaving LPA Herrera oberved water temp to be within required range Administrator to create a water temperature log for the next 5 days begining 3/6/24 and ending 3/10/24, water temp is to be tested morning, afternoon and evening, with all readings within required range. Log to be submitted to LPA via email by POC due date.

Type B

Section Cited

CCR

85064(b)

Administrator Qualifications and Duties

(b) All adult residential facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as the assigned administrator Eboni Campbell could not furnish proof of Administrator Certificate or Pending Renewal, LPAs tried calling to verify status (non found) and checked pending list on CCL website and name was not found, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2024
	Plan of Correction
1 2 3 4	Administrator to obtain proof of pending renewal and submit proof to LPA via email by POC due date, Proof must identify Eboni Campbell and be from a credible source.

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:

Tena Herrera

LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AMBIRIA HOMES II	FACILITY NUMBER: 198601562
	VISIT DATE: 02/29/2024

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Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted in October 2023.
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained in a secure location. LPA reviewed 4 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, Current First Aid/CPR/AED/CPI and sufficient on-going training. Administrator Eboni Campbell is currently undergoing a renewal on the administrator certification but was unable to furnish proof of pending renewal during visit (details will be documented in the 809-D)
Client Rights-Information: Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files are maintained in a secured locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 2 client files with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. LPAs reviewed client’s medications during todays visit with no issues.
Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually, and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills.
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques, however, staff maintain a CPI Certificate in the case of use.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during todays visit will be cited in the 809-D.

Exit interview was held and a copy of the report was given to Eboni Campbell.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

LIC809 (FAS) - (06/04)

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