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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604252
Report Date: 02/08/2024
Date Signed: 02/08/2024 02:20:04 PM

Document Has Been Signed on 02/08/2024 02:20 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:AMBROSIO HOME CAREFACILITY NUMBER:
374604252
ADMINISTRATOR:TORRES, ERNESTINAFACILITY TYPE:
735
ADDRESS:4579 JAMBOREE STREETTELEPHONE:
(442) 266-2952
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 3CENSUS: 2DATE:
02/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator Ernestina TorresTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Administrator Ernestina Torres.

The facility is licensed for a maximum capacity of 3 ambulatory clients. During today’s visit, the facility had a census of 2 ambulatory clients. Clients were not present during the time of LPA's inspection. LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Ernestina Torres and their certificate was valid and current.

During today’s visit, LPA toured the facility and inspected each room of the facility, including client rooms, bathrooms for client and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed near or on the premises. According to Ernestina Torres, no firearms or weapons are stored on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 115.3 degrees Fahrenheit and 117.9 degrees Fahrenheit in two common bathrooms. The facility’s internal temperature was measured at 68 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. LPA also observed locked storage for client medications and client and staff files. Client medications are stored in their original container and label. LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 39 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the clients that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate.

Continued on LIC809-C page...
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2024
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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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: AMBROSIO HOME CARE
FACILITY NUMBER: 374604252
VISIT DATE: 02/08/2024
NARRATIVE
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LPA reviewed multiple client and staff records. Each client record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property and cash resources, and personal rights. LPA reviewed clients’ personal and incidental money and ledger with the Administrator and did not discover any inconsistencies. Review of staff files revealed that files for Staff 1, Staff 2, and Staff 3 (S1-S3) were not complete and were missing several documents, including current first aid certificates, LIC508, and employee rights. [Administrator was provided with an LIC811 Confidential Names list to identify S1-S3]. LPA spoke with the Administrator and that interview did not reveal any licensing or regulatory concerns. Clients were not available for interview.

The Administrator will submit copies of the LIC500 Personnel Report and LIC610D Disaster Plan to the Department within 15 business days.

The following deficiencies for incomplete staff records and the lack of evacuation chair are being cited per California Code of Regulations, Title 22 and noted on the attached LIC809-D page.

An exit interview was conducted with Administrator Ernestina Torres, whose signature below confirms receipt of a copy of this report, the LIC811, and the Licensee Appeal Rights (LIC9058 01/16).
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/08/2024 02:20 PM - It Cannot Be Edited


Created By: Rebecca A Ruiz On 02/08/2024 at 01:28 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: AMBROSIO HOME CARE
FACILITY NUMBER: 374604252

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell in a residential facility serving adults, on or before July 1, 2021.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above due to not having an evacuation chair at the facility staircase which poses a potential safety risk to 2 of 2 clients in care.
POC Due Date: 02/23/2024
Plan of Correction
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Administrator purchased a stair evacuation chair during the visit and will provide LPA with proof of delivery by POC due date of 2/23/2024.
Type B
Section Cited
CCR
87412(a)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which 3 of 5 staff records were missing several documents and were not complete which poses a potential safety risk to 2 of 2 clients in care.
POC Due Date: 03/08/2024
Plan of Correction
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Administrator will ensure that staff files for S1-S3 are complete and will submit an LIC9098 Proof of Corrections to the Department by POC due date of 3/8/2024.
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
LICENSING EVALUATOR NAME:Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024


LIC809 (FAS) - (06/04)
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