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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604252
Report Date: 11/09/2022
Date Signed: 11/09/2022 12:16:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/01/2022 and conducted by Evaluator Rebecca A Ruiz
COMPLAINT CONTROL NUMBER: 08-AS-20221101143304
FACILITY NAME:AMBROSIO HOME CAREFACILITY NUMBER:
374604252
ADMINISTRATOR:TORRES, ERNESTINAFACILITY TYPE:
735
ADDRESS:4579 JAMBOREE STREETTELEPHONE:
(760) 590-4320
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:3CENSUS: 3DATE:
11/09/2022
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Ernestina TorresTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Dangerous items were accessible to clients
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced investigation visit to open a complaint investigation regarding the above mentioned allegation. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Administrator Ernestina Torres.

During today's visit, LPA toured the facility, observed clients in care, reviewed and obtained copies of facility records, and interviewed staff.

The Department's investigation consisted of interviews with staff and outside sources, records review, LPA observations, and a tour of the facility. It was alleged that dangerous items were accessible to clients. Duing today's visit, on 11/9/2022, LPA Ruiz observed a blender blade attachement in an unlocked kitchen cabinet, an unlocked knives drawer in the kitchen, and a can of disinfecting spray in an unlocked cabinet under the sink in the downstairs bathroom. Continued on LIC9099-C page...
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 08-AS-20221101143304
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: AMBROSIO HOME CARE
FACILITY NUMBER: 374604252
VISIT DATE: 11/09/2022
NARRATIVE
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 Administrator Torres moved the blender blade attachment into the knives drawer and locked it during today's visit. LPA Ruiz observed locked storage for cleaning supplies under the kitchen sink, in the garage, and in an upstairs closet. Administrator Torres moved the can of disinfecting spray into the locked storage in the garage during today's visit.

The Department has investigated the above-mentioned allegation and based on LPA observation, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page.

An exit interview was conducted with Administrator Ernestina Torres, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20221101143304
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: AMBROSIO HOME CARE
FACILITY NUMBER: 374604252
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2022
Section Cited
CCR
80087(g)
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80087(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement has not been met as evidenced by:
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Administrator moved the disinfectant spray and blender blades to locked storage and locked the knives drawer during visit. Administrator and staff will attend an in-service training on dangerous items storage and provide LPA with proof of attendance by POC due date of 11/23/2022.
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Based on LPA observations, the Administrator did not ensure that a disinfectant spray, blender blades, and knives were kept inacessible to clients. This poses an immediate health and safety risk to 3 of 3 clients in care.
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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.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3