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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200582
Report Date: 07/30/2025
Date Signed: 07/30/2025 05:38:28 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
07/23/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250723135709
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: 5DATE:
07/30/2025
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Raufat Ikharo-Umaru, AdministratorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff did not assist resident with incontinence care needs in a timely manner
INVESTIGATION FINDINGS:
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On 07/30/25 at 2:20PM, 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, physician’s report, needs & services plan, physician's report, medication administration records, incident reports.

Continued on next page, LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
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 6
Control Number 15-AS-20250723135709
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: 07/30/2025
NARRATIVE
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Allegation: Staff did not assist resident with incontinence care needs in a timely manner
Investigation Finding: Substantiated
During investigation, LPA conducted interviews with reporting party (RP), authorized representative (POA) resident (R1), staff (ADM, S1) and reviewed resident (R1) documents. LPA interviewed RP and POA who stated that on 07/23/25, RP called POA on his phone around 7:45 AM asking for help because his clothing and bedding were soaking wet and that staff was not responding to his calls (ringing his bell).

Staff (S1) confirmed with LPA that they failed to assist R1 timely with his incontinence care needs because the other staff (S2) did not show up for her scheduled work at 6AM that day. LPA also interviewed R1 who stated that another staff (S3) changed his wet clothing, diaper and bedding around 9AM on 07/23/25 since S2 did not arrive at the facility until 10AM.

Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not assist resident with incontinence care needs in a timely manner was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

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

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20250723135709
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: 07/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2025
Section Cited
CCR
87625(b)(3)
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In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
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By POC due date, ADM agrees to complete and submit to CCLD in-service staff retraining by a certified vendor on observation of resident in compliance with Section 87625(b)(3)
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This requirement was not met as evidenced by staff did not assist resident timely with incontinence care needs which posed a potential health & safety risk to residents 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: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
07/23/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250723135709

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: 5DATE:
07/30/2025
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Raufat Ikharo-Umaru, AdministratorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff interfered with resident’s visit
Staff made inappropriate comments to resident.
Staff retaliated against resident
INVESTIGATION FINDINGS:
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On 07/30/25 at 2:20PM, 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, physician’s report, needs & services plan, physician's report, medication administration records, incident reports.

Continued on next page, LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20250723135709
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: 07/30/2025
NARRATIVE
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Allegation: Staff made inappropriate comments to resident
Investigation Finding: Unsubstantiated
During investigation, LPA conducted interviews with reporting party (RP), authorized representative (POA) resident (R1), staff (ADM, S1) and reviewed resident (R1) documents. S1 stated that POA arrived at the facility at around 8AM ringing the doorbell, banging the front door and yelling for staff to open the front door. S1 stated that when she opened the front door POA started yelling at her to assist R1 with his incontinence needs. S1 stated she told POA to stop yelling to avoid agitating the other residents. S1 denied making any inappropriate comments to R1 or POA. S1 stated she politely requested POA to leave the facility at around 8:15AM because she was continuing to yell and bang on the door. 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 made inappropriate comments to resident is unsubstantiated.

Allegation: Staff interfered with resident’s visit
Investigation Finding: Unsubstantiated
During investigation, LPA conducted interviews with reporting party (RP), authorized representative (POA) resident (R1), staff (ADM, S1) and reviewed resident (R1) documents. Review of R1’s admission agreement dated 02/10/25 showed that visitors’ hours are 7 days a week from 9AM to 7PM. S1 stated that on 07/23/25, POA arrived around 8AM ringing the front door vigorously, banging on the front door and yelling for staff to open the door. S1 stated that when she opened the door, POA went straight in and yelled for staff to R1’s wet diapers, clothing and bedding right away. S1 stated she was never rude to POA and requested her to leave the facility because she was yelling and disturbing the other residents. LPA reviewed S1’s cell phone calls on 07/23/25 which showed S1 called 911 at around 8:39AM which prompted the police to arrive at the facility around 9AM. S1 stated that she allowed POA to come inside the facility around 10:30AM when R1’s transport showed up for his medical appointment. 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 interfered with resident’s visit is unsubstantiated.

Continued on next page, LIC9099-C pg2
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20250723135709
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: 07/30/2025
NARRATIVE
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Allegation: Staff retaliated against resident
Investigation Finding: Unsubstantiated
During investigation, LPA conducted interviews with reporting party (RP), authorized representative (POA) resident (R1), staff (ADM) and reviewed resident (R1) documents. LPA interviewed RP and POA who stated that staff (ADM,S1) started being rude to POA because ADM knew it was the POA who filed the previous complaints against the facility. ADM denied retaliating against POA. ADM stated she let POA attend their barbeque celebration with residents on 07/20/25 when R1 informed her of the event on 07/20/25. ADM also stated she answered POA’s text messages regarding R1’s relocation plans on 07/22/25. 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 retaliated against the resident 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: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6