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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200582
Report Date: 07/02/2025
Date Signed: 07/02/2025 03:08:15 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
06/24/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250624103807
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: DATE:
07/02/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Raufat Ikharo-Umaru, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not meet resident’s hygiene needs which led resident to develop a UTI
INVESTIGATION FINDINGS:
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On 07/02/25 at 3PM, 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 staff.

During investigation, LPA conducted interviews with reporting party (RP), staff (ADM, S1), resident (R1), authorized representative (POA) and obtained the following documents from administrator – Personnel record (LIC500), Residents roster, admission agreement, reappraisals, needs & services plan, physician's report, centrally stored medication logs, medication administration records, incident reports.

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: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
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 2
Control Number 15-AS-20250624103807
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: 07/02/2025
NARRATIVE
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Allegation: Staff did not meet resident’s hygiene needs which led resident to develop UTI
Investigation Finding: Unsubstantiated
During investigation, LPA conducted interviews with, reporting party (RP), authorized representative (POA) resident (R1), staff (S1) and reviewed resident (R1) documents. LPA interviewed staff (ADM, S1) who stated that they gave R1 full baths 2X per week and changed his diapers every 3 hours.

On 07/02/25 at 2PM, R1 confirmed with LPA that staff changed his diapers 3X per day or as needed and gave him showers 2X per week (every Saturday and Thursday). LPA observed R1 to be clean, odor free and well groomed. 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 did not meet resident’s hygiene needs which led resident to develop UTI is unsubstantiated.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC9099 (FAS) - (06/04)
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