Inspection Reports for Ambassadors Care Home

An unannounced complaint investigation visit was conducted in response to allegations that staff did not assist a resident with incontinence care needs in a timely manner, interfered with the resident's visit, made inappropriate comments to the resident, and retaliated against the resident.

The investigation substantiated the allegation that staff failed to assist the resident timely with incontinence care needs due to staff absence, posing a potential health and safety risk. The other allegations regarding interference with the resident's visit, inappropriate comments, and retaliation were found to be unsubstantiated based on the preponderance of evidence.

The complaint investigation was substantiated for the allegation that staff did not assist the resident with incontinence care needs in a timely manner. The investigation included interviews with the reporting party, authorized representative, resident, and staff, as well as review of relevant documents. Other allegations of staff interfering with the resident's visit, making inappropriate comments, and retaliating against the resident were unsubstantiated.

An unannounced complaint investigation visit was conducted in response to an allegation that staff did not meet a resident's hygiene needs which led to the resident developing a UTI.

The investigation found the allegation to be unsubstantiated. Interviews and document reviews indicated that the resident received regular hygiene care, including full baths twice weekly and diaper changes every three hours. The resident was observed to be clean, odor free, and well groomed.

The complaint alleged that staff did not meet the resident’s hygiene needs which led to the resident developing a UTI. The investigation was unsubstantiated due to lack of preponderance of evidence.

An unannounced complaint investigation visit was conducted following allegations that staff failed to observe a change in a resident's condition and failed to meet the resident's medical needs in a timely manner.

The investigation substantiated both allegations, finding that staff did not observe the resident's change in condition and failed to meet the resident's medical needs promptly, which posed a potential health and safety risk to the resident.

The complaint investigation was substantiated based on interviews with the reporting party, authorized representative, resident, and staff, as well as review of resident records. The resident was diagnosed with a stroke and urinary tract infection after staff failed to recognize changes in condition and delayed medical response.

An unannounced complaint investigation visit was conducted in response to allegations that staff were not assisting a resident with glucose testing and that staff falsified the resident's glucose readings.

The investigation found no preponderance of evidence to prove the alleged violations occurred. The allegation that staff did not assist with glucose testing was unsubstantiated, and the allegation of falsifying glucose readings was unfounded. No deficiencies were cited.

The complaint involved two allegations: 1) staff not ensuring assistance with glucose testing, and 2) staff falsifying resident's glucose readings. Both allegations were investigated and found unsubstantiated or unfounded based on interviews and medical record reviews.

The visit was an unannounced Case Management inspection conducted on 04/15/2025, including a complaint investigation (15-AS-20241104220736) related to fingerprint clearance and staff communication issues.

The inspection found that a staff member (S2) was not fingerprinted or associated with the facility and was unable to communicate in English, posing an immediate health and safety risk. An immediate civil penalty of $100 was assessed for fingerprint clearance violations.

The complaint investigation (15-AS-20241104220736) revealed that a staff member was not fingerprinted and could not communicate in English, which posed an immediate health and safety risk.

Unannounced complaint investigation visit conducted due to allegations that staff did not meet residents' diapering needs, did not respond timely to residents' calls for assistance, and did not provide adequate food service.

The investigation substantiated the allegations that staff failed to timely change incontinent residents, respond promptly to residents' calls for assistance due to insufficient staffing and lack of call system, and provided inadequate food service with meals high in carbohydrates and insufficient perishables. The facility was cited under California Code of Regulations for these deficiencies.

The complaint investigation was substantiated based on interviews, observations, and record reviews. Allegations included unmet diapering needs, delayed response to resident calls due to staffing shortages and lack of call system, and inadequate food service. The facility was cited accordingly.

An unannounced annual required inspection was conducted to evaluate compliance with licensing regulations and assess the facility's condition and resident care.

The inspection revealed multiple deficiencies including incomplete staff and resident files, lack of hot water in the shared bathroom, unlocked cabinets containing hazardous materials, broken exit door with a bolt lock, inadequate food supplies, missing health care plans, failure to conduct fire drills, and improper medication storage. An immediate $500 civil penalty was assessed for fire safety violations.

The visit was an unannounced complaint investigation conducted in response to allegations that staff made inappropriate comments towards a resident and yelled at the resident.

The investigation found no preponderance of evidence to substantiate the allegations. Interviews with the resident and staff indicated that while disagreements occurred, staff did not yell at or call the resident names. No deficiencies were cited during the visit.

The complaint involved allegations that staff made inappropriate comments towards a resident and yelled at the resident. The allegations were found to be unsubstantiated due to lack of evidence.

Unannounced complaint investigation visit conducted due to an allegation of illegal eviction of a resident.

The investigation found the allegation of illegal eviction to be unsubstantiated after review of records, interviews, and observations. No deficiencies were cited during the visit.

Allegation: Illegal eviction of resident. Investigation finding: Unsubstantiated. The resident was observed still residing at the facility, and documentation showed a 30-day eviction notice was sent for non-payment. The administrator is working with the resident's County Conservator for safe relocation.

The visit was an unannounced annual required inspection conducted by the Licensing Program Analyst to evaluate compliance with state regulations.

The inspection found two deficiencies: an expired fire extinguisher and a missing carbon monoxide detector, both posing potential health and safety risks to residents.

The visit was an unannounced infection control inspection conducted as part of the required 1-year evaluation.

The inspection found no deficiencies. The facility had appropriate infection control measures in place, including screening, PPE supplies, social distancing signage, and a mitigation plan. Updated documents were requested for submission.