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Type of visit: Required - 1 Year

On 09/10/25 at 2PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. At 2:30PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 75 deg F. Hot water temperature was measured at 110 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Two fire extinguishers were observed fully charged and purchased new on 08/27/25. LPA reviewed 2 staff and 5 resident files. Updated copies of the following documents were obtained for facility file:  LIC500- Personnel Report  Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 10, 2025

Allegation investigated: Staff did not ensure resident’s wound care needs were met resulting in hospitalization

On 03/07/25 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit to deliver the findings of the allegations. LPA explained the purpose of the visit with Administrator (ADM). During investigation, the department obtained the following documents from administrator – personnel record (LIC500) residents’ roster, admission agreement, physician's report, preplacement appraisal, hospice care plan, emergency information, responsible party (POA) information, home heath reports. Health & safety check conducted see LIC 809 dated 02/13/25. Continued on next page, LIC 9099-C Substantiated ALLEGATION: Staff did not ensure resident’s wound care needs were met resulting in hospitalization INVESTIGATION FINDING: Substantiated During investigation, the department conducted interviews of facility staff (ADM, S1) and third party witness (W1) and reviewed resident’s (R1) documents. Review of R1’s records showed she was first admitted at Ambassador Care Home on 07/30/2019 when she was 88 years old. ADM stated R1 was verbal, ambulatory and required minimal assistance with activities of daily living such as personal hygiene, toileting, dressing, grooming, meals, medications, doctors’ appointments. On October 2023, R1’s (92 years old) health gradually declined with very poor appetite, severe weakness and weight loss. R1 was placed under hospice care by responsible party (POA) and primary care physician (PCP). She remained stable and was discharged from hospice on April 2024 with quarterly visits from her PCP, nurse (W1) and home health care team. W1 stated she was the primary care nurse for R1, visited and checked on her once a month for the past two years and worked with the home health team to care for R1. She noticed a new stage 2 pressure injury on R1’s coccyx on 07/26/24. She reminded staff to reposition R1 every 2 hours daily as prescribed. However, W1 stated she noticed that there was only one staff caring for 5 residents during her unannounced visits. W1 also stated R1 was not turned or repositioned every 2 hours because R1 was found by home health nurse in the same position from last visit. On 12/04/24, R1 was sent to the hospital ER because her wound had developed an odor. R1's was diagnosed with stage 3 coccyx pressure injury and a wound vacuum was prescribed with home health visits 3X per week. On 01/22/25, R1 was again sent to the hospital due to declining health. R1 was diagnosed with stage 4 coccyx injury and infection. Based on observations and interviews which were conducted and record review(s), the department has substantiated the allegation that staff did not ensure resident’s wound care needs were met resulting in hospitalization. The preponderance of evidence standard has been met. Therefore, the above allegation was found to be substantiated. Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in resident being hospitalized twice while in care. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date 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. Allegation: Staff did not provide proper food service to resident in care Finding: Unsubstantiated During investigation, LPA interviewed staff (ADM), third part witness (W1) and reviewed R1’ documents. Review of R1’ documents showed that on 10/2023, R1 was placed under hospice care by her responsible party (POA) and primary care physician (PCP) due to very poor appetite, severe weakness and weight loss. ADM stated R1 remained stable with hospice and was later discharged from hospice in April 2024. ADM stated that R1’s nutritionist placed her on ensure with protein supplement to help with wound healing. Home Health care team managed R1’s wound with a wound vacuum placed on the wound and visited R1 three times per week to help with wound healing. R1 lost a lot of weight because she refused to eat her meals and had no interest in eating or drinking. As a result, her wound was not healing due to her very poor nutritional intake. On 12/05/24, staff sent R1 to the hospital because her wound had developed an odor, would not heal, continued loss of appetite and severe weight loss. ADM stated R1’s food intake remained very poor despite staff physically putting food and liquid into her mouth. 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 provide proper food service to resident in care was found to be unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 7, 2025 · control 15-AS-20250213093047

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 7, 2025

To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by staff failing to provide adequate care and supervision to resident resulting in resident being hospitalized twice which posed an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 7, 2025

Plan of correction: Immediate civil penalty of $500 assessed during visit.

Type of visit: Case Management - Health Checks

On 02/13/25 at 2:23PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Health and Safety check due to the department receiving a priority 2 complaint. During the health and safety check, LPA observed a total of 2 staff members and 5 residents at the facility. LPA toured facility, including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 13, 2025

Type of visit: Required - 1 Year

On 08/30/24 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with staff (S1) and spoke to administrator (ADM) on the phone who authorized S1 to act on her behalf and sign the reports. LPA explained the purpose of the visit with S1 and ADM. At 12:45 PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy and visitor’s logs were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 78 deg F. Hot water temperature was measured at 111 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 2 staff and 5 resident files. LPA observed the following deficiencies during visit: Broken front gate Unlocked bleach in bathroom One staff not fingerprint cleared & associated to facility (Immediate civil penalty of $500 assessed during visit) Personnel records not available for inspection at facility during visit Personnel records not maintained at facility Continued on next page, LIC 809-C Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Updated copies of the following documents were obtained for facility file:  LIC500- Personnel Report  Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 30, 2024