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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701166
Report Date: 05/08/2023
Date Signed: 05/08/2023 03:37:35 PM

Document Has Been Signed on 05/08/2023 03:37 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:AMBASSADOR RESIDENTIAL CARE HOMEFACILITY NUMBER:
502701166
ADMINISTRATOR:NKWOCHA, ONYEMA GILBERTFACILITY TYPE:
735
ADDRESS:2708 TYPHOON AVETELEPHONE:
(209) 275-3272
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 4CENSUS: 0DATE:
05/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Augusta and Onyema NwochaTIME COMPLETED:
11:00 AM
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On 05/08/2023 at 10:00am, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with Licensee Augusta and Onyema Nwocha and explained the purpose of the visit. This facility is licensed to serve 4 residents, 1 one which may be non-ambulatory. This facility is awaiting vendorization from Valley Mountain Regional Center to serve and retain 4I residents.
Current Census was 0.
A tour of the facility was conducted.

The fire extinguisher, located in the front hallway, was serviced by Jorgensen Fire Company and is valid until 07/20/2023. All smoke detectors were present and working at this time.
Four resident bedrooms were toured. Furniture and furnishing were observed to be present and in good condition. An office was toured and was observed to be in good repair.
Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
A linen closet was located in the hallway. LPA observed a sufficient amount of linens at this time.
A tour of the bathrooms was conducted. Hot water temperatures were taken to ensure that the hot water being dispensed was within the allowed range of 105-120 degrees at all times.
The kitchen area was toured. Facility freezer and refrigerator showed to be functional and in compliance at this time. LPA observed that there was a sufficient amount of 2-day perishable and 7-day nonperishable food supplies available at this time.
Garage area was toured. LPA observed a refrigerator which will store additional food supplies. Additional storage for supplies were stored in cabinets.
This facility will be using a medication cabinet which was located in the living room. LPA observed the medication cabinet to be locked and made inaccessible at this time.
First aid kit was observed to be present and contained all of the required components at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2023
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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: AMBASSADOR RESIDENTIAL CARE HOME
FACILITY NUMBER: 502701166
VISIT DATE: 05/08/2023
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Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and in compliance at this time.

Exterior grounds of this facility was toured. Perimeter fence and gates were checked and presented no hazards at this time.

The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

-Liability insurance

No deficiencies were observed or cited during this annual visit.

Exit interview was conducted and a copy of this report was provided to the facility at the end of the visit.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC809 (FAS) - (06/04)
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