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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701166
Report Date: 11/19/2024
Date Signed: 11/20/2024 07:20:46 AM

Document Has Been Signed on 11/20/2024 07:20 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AMBASSADOR RESIDENTIAL CARE HOMEFACILITY NUMBER:
502701166
ADMINISTRATOR/
DIRECTOR:		NKWOCHA, ONYEMA GILBERTFACILITY TYPE:
735
ADDRESS:2708 TYPHOON AVETELEPHONE:
(209) 275-3272
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 4CENSUS: 4DATE:
11/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Augusta NkwochaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 11/19/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA met with Licensee, Augusta Nkwocha and explained the purpose of the visit.
Current census was 3. A brief interview with Licensee Nkwocha was conducted.

The purpose of this visit was to follow up on an incident report that was sent by the facility on 11/17/2024. It was stated that R1 went to the Emergency room to be evaluated due to the resident stating that they had swallowed a foreign object. R1 was released from the Emergency Room and the hospital did not find any indication that the resident had swallowed a foreign object.

Based on interviews conducted, it was learned that R1 had provided a false statement to staff to get out of going to their day program the next day. It was learned that R1 was not getting along with another consumer at the day program. The facility administrator contacted the residents Service Coordinator and informed them of the incident and notified the day program to best help R1.
A care conference will be conducted to develop a plan in place to best help the resident.

Based on the information gathered, there are no deficiencies being cited during this case management visit.
An exit interview was conducted and a copy of this report was provided to the Licensee at the end of this visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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