374602452-2-29-2024-08-AS-NPED-D2WLXT-20240229080913

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602452
Report Date: 02/28/2024
Date Signed: 02/29/2024 08:09:39 AM

Document Has Been Signed on 02/29/2024 08:09 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	AMBASSADOR SENIOR RETREAT I		FACILITY NUMBER:	374602452
ADMINISTRATOR:	IRIS RAMIREZ		FACILITY TYPE:	740
ADDRESS:	8235 HYDRA LANE		TELEPHONE:	(858) 564-9490
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92126
CAPACITY:	6	CENSUS: 6	DATE:	02/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Licensee, Iris Ramirez		TIME COMPLETED:	05:45 PM

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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. LPA was greeted and allowed entry into the facility by Staff, Erlinda Agcaoili. Licensee, Iris Ramirez was present and conducted the visit with LPA.

LPA, accompanied by licensee, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant and measured at 120 F.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. However, medications are being pre-poured 24 hours in advance.

No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detector, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. The reviewed files contained required documents. Confidential records were stored in locked area.

A deficiency was observed during today's annual inspection and cited on the attached LIC 809D. An exit interview was conducted with Licensee, Iris Ramirez to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

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 02/29/2024 08:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: AMBASSADOR SENIOR RETREAT I	FACILITY NUMBER: 374602452
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and interviews, the licensee did not store medication in it's original container by pre-pouring medications 24 hours in advance for 5 out of 5 residents [R1-R5] which poses a potential health and safety risk to persons in care.
	POC Due Date: 03/27/2024
	Plan of Correction
1 2 3 4	Licensee will dispense the pre-poured medications for all residents tonight for PM/bedtime and agreed not to pre-pour medications. Licensee will attend medication training and provide proof of training by POC due date.

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

LIC809 (FAS) - (06/04)

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