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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294217
Report Date: 11/15/2021
Date Signed: 11/16/2021 08:30:22 AM

Document Has Been Signed on 11/16/2021 08:30 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:AMBROSIA HOMEFACILITY NUMBER:
435294217
ADMINISTRATOR:ARELLANO, ROSARIOFACILITY TYPE:
740
ADDRESS:4094 WEST RINCON AVENUETELEPHONE:
(408) 374-3965
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 6CENSUS: 3DATE:
11/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:13 PM
MET WITH:Helen IbrahimTIME COMPLETED:
04:31 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 11/15/2021 at 03:13pm. LPA met with facility Administrator Helen Ibrahim (Admin).

LPA toured the facility, including living room, kitchen, dining room, office, 5 client bedrooms, 3 bathrooms, 1 staff bedroom and back yard. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated.

No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizer and soap were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguishers observed to be inspected in March 2021. Facility fire alarms tested and observed to be in working order. Facility water temperature observed to be 120.1 *F.

Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. 30 day supply of PPE observed. Restrooms observed to not be stocked with paper towels. LPA advised Admin to place paper towel rolls in all facility bathrooms. Hand washing signs observed in all bathrooms. Social distancing signs observed to be posted in all public areas. The facility is currently accepting visitors inside the facility, including residents' bedrooms.

No deficiencies cited during today's visit. This report was reviewed with Administrator Helen Ibrahim and a copy of the signed report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2021
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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