079200582-5-29-2025-15-AS-KHOS-DH9PZD-20250602114523

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200582
Report Date: 05/29/2025
Date Signed: 05/29/2025 01:59:00 PM

Unsubstantiated

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
05/22/2025 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20250522095120

FACILITY NAME:	AMBASSADOR CARE HOME		FACILITY NUMBER:	079200582
ADMINISTRATOR:	IKHARO-UMARU, RAUFAT		FACILITY TYPE:	740
ADDRESS:	145 BEEDE WAY		TELEPHONE:	(510) 812-2188
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	6	CENSUS: 4	DATE:	05/29/2025
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Raufat Ikharo-Umaru, Administrator		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff are not ensuring that resident is being assisted with glucose testing
Staff falsified resident's glucose readings

INVESTIGATION FINDINGS:

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On 05/29/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (ADM, S1), gathered information and delivered investigation findings to ADM. LPA explained the purpose of the visit with ADM.

At 1:10PM, LPA interviewed staff (ADM) and reviewed the following documents: Personnel record (LIC500), Residents’ roster, admission agreement, physician’s report, Hospice care plan, centrally stored medication logs, after discharge summary report, discontinued PCP orders for glucose testing and insulin shots.

Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250522095120

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: 05/29/2025

NARRATIVE

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Allegation: Staff are not ensuring that resident is being assisted with glucose testing
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed reporting party (RP), staff (ADM) and reviewed hospice resident’s (R1) admission agreement, physician’s report, hospice care plan, centrally stored medication logs, after visit summary report, discontinued orders of glucose testing and insulin medication from R1’s PCP. Review of R1’s physician’s report dated 03/28/25 showed he was not diabetic and did not require glucose testing. On 04/29/25, he was sent to the hospital for a change in condition. Review of the hospital after visit report dated 05/03/25 showed doctor’s orders for glucose testing and insulin shots to be administered 2X per day. ADM assisted R1 with glucose testing and insulin shots from 05/04/25 until 05/26/25. LPA reviewed written records of R1’s glucose testing and insulin shots from 05/04/25 until 05/26/25. Review of R1’s medical records showed R1’s glucose testing and insulin medication were discontinued by his PCP on 05/26/25. On 05/27/25 at 3PM, RP confirmed with LPA that R1’s glucose testing and insulin medication were discontinued by his primary care physician (PCP) on 05/26/25 since he was under hospice comfort care. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not ensuring that resident is being assisted with glucose testing is unsubstantiated.

Allegation: Staff falsified resident’s glucose readings
Investigation Finding: Unfounded
During investigation, LPA interviewed reporting party (RP) and staff (ADM) and reviewed hospice R1’s medical records. LPA reviewed written records of R1’s glucose testing and insulin shots from 05/04/25 until 05/26/25. On 05/27/25 at 3PM, RP confirmed with LPA that R1’s glucose testing and insulin medication were discontinued by his primary care physician (PCP) on 05/26/25 since he was under hospice comfort care Staff denied falsifying R1’s glucose readings. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff falsified resident’s glucose readings is unsubstantiated.

No deficiencies cited. Exit Interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

LIC9099 (FAS) - (06/04)

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