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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202338
Report Date: 03/23/2022
Date Signed: 03/23/2022 01:32:23 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/14/2022 and conducted by Evaluator Marybeth Donovan
COMPLAINT CONTROL NUMBER: 26-AS-20220314164138
FACILITY NAME:AMBROSIA SENIOR CAREFACILITY NUMBER:
435202338
ADMINISTRATOR:HELEN IBRAHIMFACILITY TYPE:
740
ADDRESS:1176 WESTWOOD DRIVETELEPHONE:
(408) 460-6656
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: 4DATE:
03/23/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Helen IbrahimTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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9
Unlawful eviction of resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced visit to open a 10 Day complaint investigation regarding the above allegation. LPA met with Helen Ibrahim Administrator and explained the purpose of the visit.

LPA interviewed Administrator and family member. LPA reviewed resident (R1) records to include admission agreement, emergency contact information, hospice records, Power of Attorney, physician's report, medical records, functional capabilities, care plan and incident reports. LPA reviewed written statements from family member and medical care provider.

Administrator stated that R1 was not evicted. The facility would evaluate R1's return prior discharge after re-assessment. Records review noted no eviction was given to R1 and or family member/responsible party. Family member confirmed no eviction notice was given. Subsequently, on 3/15/2022, the reporting party stated during phone conference with Administrator and family member confirmed that no eviction was given.

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Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
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 2
Control Number 26-AS-20220314164138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: AMBROSIA SENIOR CARE
FACILITY NUMBER: 435202338
VISIT DATE: 03/23/2022
NARRATIVE
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.The Department has investigated the above allegation. Based on interviews conducted and documents review, the Department found the above allegation to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No deficiencies were cited during today’s visit.

This report was reviewed with Helen Ibrahim Administrator and a copy was provided.

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SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2