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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294217
Report Date: 11/08/2022
Date Signed: 11/08/2022 04:54:39 PM


Document Has Been Signed on 11/08/2022 04:54 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:AMBROSIA HOMEFACILITY NUMBER:
435294217
ADMINISTRATOR:IBRAHIM, HELENFACILITY TYPE:
740
ADDRESS:4094 WEST RINCON AVENUETELEPHONE:
(408) 460-6656
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:6CENSUS: 5DATE:
11/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Helen IbrahimTIME COMPLETED:
04:06 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 11/08/2022 at 03:01pm. LPA met with facility Administrator Helen Ibrahim (Admin).

LPA toured the facility, including living room, kitchen, dining room, office, 5 client bedrooms, 3 bathrooms, 1 staff bedroom, and back yard. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated.

No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizer and soap were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguishers observed to be inspected in March 2022. Facility water temperature observed to be within acceptable levels. Facility temperature observed to be 70*F.

Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. 30 day supply of PPE observed. Restrooms observed to be stocked with paper towels. LPA advised Admin to place paper towel rolls in all facility bathrooms. Hand washing signs observed in all bathrooms. Social distancing signs observed to be posted in all public areas. Facility infectious control plan has already been submitted to licensing.

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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
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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