<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202338
Report Date: 11/11/2023
Date Signed: 11/11/2023 10:35:08 AM


Document Has Been Signed on 11/11/2023 10:35 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



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: 5DATE:
11/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Helen IbrahimTIME COMPLETED:
10:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Helen Ibrahim . During visit, LPA observed 5 residents and 2 staff.

LPA toured the facility inside out with ADM which included; the Living room, kitchen, dining room, 4 restrooms and 6 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication closet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 77 degrees F, and hot water temperature was measured at 3 restrooms, and the water temperature was measured to range from 112-115 degrees F.

Fire extinguisher was serviced in March 11, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on September 29, 2023.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 3 staff (S1 to S3) and 3 residents (R1-R3).

No deficiencies cited during today's visit. This report was reviewed with Administrator Helen Ibrahim and a copy of the signed report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 11/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1