435294217-10-24-2024-26-AS-MTAN-DACR6U-20241024124520

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435294217
Report Date: 10/24/2024
Date Signed: 10/24/2024 12:45:33 PM

Document Has Been Signed on 10/24/2024 12:45 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 HOME		FACILITY NUMBER:	435294217
ADMINISTRATOR:	IBRAHIM, HELEN		FACILITY TYPE:	740
ADDRESS:	4094 WEST RINCON AVENUE		TELEPHONE:	(408) 460-6656
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	6	CENSUS: 5	DATE:	10/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Helen Ibrahim		TIME COMPLETED:	12:45 PM

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) Marcella Tarin conducted an unannounced annual inspection visit at 9:15AM and met with Administrator, Helen Ibrahim. LPA toured the facility inside and out with the Administrator to include the living room, dining room, kitchen, resident bedrooms, bathrooms, and exterior. All emergency exits were observed to be clear of obstruction. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature maintained at 40 degrees F and freezer maintained at -0 degrees F. LPA observed toxins, sharps and chemicals locked and inaccessible to residents. LPA toured 5 resident bedrooms. 5 out of 5 resident bedrooms had beds, a dresser, functioning lights, storage space for personal belongings, clean bedding, and a chair. LPA measured hot water temperature, range of 105.2 to 112 degrees F for 2 out of 2 resident bathrooms. The facility was equipped with smoke and carbon monoxide detectors. Fire extinguishers were last serviced on 03/13/2024. LPA observed the facility first aid kit, and it was observed to be complete. The facility fire/earthquake drill log was reviewed, and drills are being conducted quarterly. The last fire drill was conducted on 09/2/2024. Facility has emergency disaster plan. LPA reviewed 5 residents Centrally Stored Medication and Destruction Records (CSMDR). 5 out of 5 residents CSMDRs are complete with all medications accounted and documented. LPA observed the medication storage area was locked and inaccessible to residents in care.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: AMBROSIA HOME	FACILITY NUMBER: 435294217
	VISIT DATE: 10/24/2024

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LPA reviewed 5 out of 5 resident records. LPA observed 5 out of 5 resident records to contain identification and emergency contact information, personal rights, TB results and consent forms. 2 out of 5 Residents (R4 and R5) records did not contain updated physician's reports. Administrator stated the R4 and R5 had a physician's reported updated on 10/23/2024. Administrator stated she will obtain the updated reports from the physician. Administrator states she was updating residents charts. LPA advised Administrator that all resident records should be available to the licensing agency to inspect and audit. Administrator stated the physician's reports were updated on 10/23/2024 and would obtain the updated reports by 10/29/2024.

LPA reviewed 3 out of 3 staff records. LPA observed 3 out of 3 records as complete to include fingerprint clearance, health screening, TB result, personnel record, and staff training.

A Technical Assistance was issued today. See LIC809D. Exit interview was conducted with Administrator Helen Ibrahim. This report was provided to Administrator and appeals rights were provided.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC809 (FAS) - (06/04)

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