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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200582
Report Date: 04/15/2025
Date Signed: 04/15/2025 05:33:59 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/04/2024 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20241104220736
FACILITY NAME:AMBASSADOR CARE HOMEFACILITY NUMBER:
079200582
ADMINISTRATOR:IKHARO-UMARU, RAUFATFACILITY TYPE:
740
ADDRESS:145 BEEDE WAYTELEPHONE:
(510) 812-2188
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 3DATE:
04/15/2025
UNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Raufat Ikharo-Umaru, AdministratorTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Staff did not meet resident's diapering needs

Staff do not respond to resident's call for assistance in a timely manner

Staff do not provide adequate food service
INVESTIGATION FINDINGS:
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On 4/15/2025 at 4:40pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Raufat Ikharo-Umaru, Administrator, and explained the reason for the visit.

During the course of the investigation the Department conducted interviews with witnesses, staff, residents, reviewed and obtained records.

Allegation: Staff did not meet resident's diapering needs

Based on initial interview with W1 it was stated R1 was left in a soiled diaper from 9pm until 6:30am, however, during the day R1 is changed every 3 – 4 hours. Upon LPA’s

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 15-AS-20241104220736
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AMBASSADOR CARE HOME
FACILITY NUMBER: 079200582
VISIT DATE: 04/15/2025
NARRATIVE
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Continued from LIC9099.

arrival R1 had not been changed since the night prior. S2 stated normally there are two (2) staff at the facility, but there are times there is just one (1) staff to tend to all the residents. R1 and R2 stated there is just one (1) staff at the facility during the day and night. During LPA’s visit on November 12, 2024, there was only one (1) staff (S2) present. LPA observed S2 cooking, passing medication, and cleaning. S3 arrived at approximately 2:30pm. LPA reviewed the personnel report and observed there is only one (1) staff during the day and night. The personnel report indicated S3 works 12:00am – 8:00am.

Allegation: Staff do not respond to resident's call for assistance in a timely manner.

Based on initial interviews with W1 and W2, R1 must yell for assistance due to there being only one (1) staff on duty and there is not any type of call system. W1 also stated R1 is told staff are busy cleaning and she would have to wait. S2 stated that sometimes a resident will have to wait due to there is only one (1) staff and the other residents needs tending to also. R1 stated the facility does not have any type of call pendent to alert the staff when assistance is needed and if the staff is asleep in the front of the facility, they are not able to hear the residents calling for assistance. LPA observed only one (1) resident was ambulatory. During LPA’s visit LPA witnessed R1 yelling for S2 assistance.

Allegation: Staff do not provide adequate food service

W1 stated during initial interview the foods provided to the residents are not adequate. The facility offers meals that are heavy in carbohydrates and is not good for the residents with a diagnosis of diabetes. W1 stated during interview that the facility offers a lot of pastas, pancakes, and cereals. Grocery shopping is done by

Continued on LIC9099C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20241104220736
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AMBASSADOR CARE HOME
FACILITY NUMBER: 079200582
VISIT DATE: 04/15/2025
NARRATIVE
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Continued from LIC9099C.

S1 or S3, stated S2 during interview. R1 stated during interview that her family brings her food often because she is not able to eat most foods provided by the facility. LPA conducted a tour during the annual visit of the facility on November 12, 2024, and observed the facility did not have a 7-day supply of perishables and 2-day non-perishables foods for residents. LPA observed frozen meats, a few canned goods, no vegetables or fruits. LPA cited the facility under the annual inspection visit on November 12, 2024.

Based on observations, interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of the appeal rights and this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20241104220736
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AMBASSADOR CARE HOME
FACILITY NUMBER: 079200582
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2025
Section Cited
CCR
87625(b)(2)
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(b)...the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This requirement was not met as evidence by:
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Administrator agreed submit a written on plan on scheduling for incontinent residents and create a schedule and submit both to CCLD by POC date.
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Based on interviews the Licensee did not comply with the section cited above in ensuring incontinent residents are changed checked and changed timely, which poses a potential health and safety risk to persons in care.
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Type B
04/22/2025
Section Cited
CCR
87468.2(a)(4)
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(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidence by:
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LPA observed upon arrival on 4/15/2025, that each resident had a call bell to notify staff that they need assistance. Deficiency cleared.
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Based on interviews the Licensee did not comply with the section cited above in responding to resident in a timely manner, which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4