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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608472
Report Date: 07/06/2022
Date Signed: 07/06/2022 11:43:26 AM

Document Has Been Signed on 07/06/2022 11:43 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:AMBITIONS - ROSE HOUSEFACILITY NUMBER:
197608472
ADMINISTRATOR:MONIQUE TATEFACILITY TYPE:
735
ADDRESS:1132 N ROSE STTELEPHONE:
(310) 817-6100
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 3CENSUS: 3DATE:
07/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Maria Guzman, Lead CargiverTIME COMPLETED:
11:57 AM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Alberto Lopez conducted an unannounced annual visit focusing on infection control at the facility. LPA Lopez met with Sandra Montes, the 1:1 for one client and explained the reason for the visit. Maria Guzman, lead caregiver arrived 10 minutes later.

The facility is licensed to serve 3 non-ambulatory clients between 18 to 59 years old. Facility is a one story single home, with an attached garage. There are no large bodies of water in the facility. Facility has a living/dining,,,,, room, a kitchen, an office space, 3 client bedrooms, 1 client bathroom, 1 staff bathroom, a front yard and a back yard with shaded sitting area.

LPA conducted a tour of the facility and observed the following:
Facility's Kitchen has sufficient food supplies for 2 days of perishables, and 7 days of non-perishables; LPA observed fresh fruit, frozen meats, vegetables, can foods and additional emergency food supplies and water. Kitchen sink's water temperature was measured at 112.4 degrees F. Sharps/knives were locked in a cabinet to the right above the sink, and cleaning supplies were lock under the sink. LPA observed and review first aid kit on cabinet on top of refrigerator which has all the required items. LPA observed medication cabinet in office space area and is kept locked. Bedrooms #1, #2, #3 have proper lighting, and furniture; beds have all the required bedding. Client's bathroom #1 was observed to have skid mats, handle grab bars, client's hygiene products kept in cabinet, and water temperature was tested at 114.8 degrees F. LPA reviewed 3 clients' medications.
Facility is following COVID 19 recommendations, signs were observed throughout the facility, screening for staff, clients, and visitors is conducted, hand washing posters in each bathroom along with hand soap and paper towels. Staff were observed wearing face masks.
Per Title 22 regulations, deficiencies were cited during this visit. (see 809D) Exit interview was conducted with Maria Guzman, lead caregiver; a copy of this report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2022
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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Document Has Been Signed on 07/06/2022 11:43 AM - It Cannot Be Edited


Created By: Alberto Lopez On 07/06/2022 at 11:15 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AMBITIONS - ROSE HOUSE
FACILITY NUMBER: 197608472

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, three window screens where observed by LPA and Maria Guzman, Lead Caregiver in disrepair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2022
Plan of Correction
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Licensee will replace or repair window screens by POC date and send photos as proof of correction to LPA.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, LPA and Lead caregiver Maria Guzman observed facet in cleint restroom sink had facet that were not operating properly and hard to turn which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2022
Plan of Correction
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Licensee will replace or repair facet in small restroom sink by POC date and send LPA photo as proof.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stefanie Coronel
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022


LIC809 (FAS) - (06/04)
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