197608472-12-14-2023-31-AS-LNCA-CYHVRV-20231214154034

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608472
Report Date: 12/14/2023
Date Signed: 12/14/2023 03:40:44 PM

Document Has Been Signed on 12/14/2023 03:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	AMBITIONS - ROSE HOUSE		FACILITY NUMBER:	197608472
ADMINISTRATOR:	MONIQUE TATE		FACILITY TYPE:	735
ADDRESS:	1132 N ROSE ST		TELEPHONE:	(310) 817-6100
CITY:	BURBANK	STATE: CA	ZIP CODE:	91505
CAPACITY: 3		CENSUS: 3	DATE:	12/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Blanca Esparanza- Administrator		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA met with staff, Maria Guzman (caregiver) and explained the reason for the visit. LPA advised staff to please contact administrator and approximately, around 10:30am Blanca Esparza the administrator arrived. At 10:20 am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen and the hallway. The charge date is 1.13.2023. During the visit the facility is at 71 degrees Fahrenheit. The facility is fire cleared for three (03) non-ambulatory. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked cabinet in the kitchen. The menu was posted on the refrigerator for review (ARF), snacks and beverages are available for the resident in the facility when they want. Frozen foods are properly wrapped and stored appropriately and dated. Food storage and preparation areas are clean and inaccessible to pests. Office space is in the beside the kitchen area, where records are stored. Properly labeled medications were locked in the kitchen area cabinets. Bedrooms: There were three (3) bedrooms designated for residents' use. All of the bedrooms, are in use by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Room 1#, #2 and #3 are properly furnished and occupied by only one (1) resident. There is no live-in staff in the facility. Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMBITIONS - ROSE HOUSE	FACILITY NUMBER: 197608472
	VISIT DATE: 12/14/2023

NARRATIVE

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Bathrooms: There are two (2) bathrooms designated for one (1) for staff bathroom and one (1) for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 140 degrees Fahrenheit for residents bathroom for residents is located in the hallway beside the office. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. Staff bathroom is located beside resident room #1.

Common Areas: These included the living room and dining area for residents. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Residents dining table fits enough for four(4).

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. Cleaning supplies are being stored in a locked cabinet in the laundry room. The laundry area and detergents are located by the laundry room at the end of the hallway in between room #2 and room #1 that are kept secured. The facility does not have a swimming pool or body of water. The garage is attached and is used as a storage for incontinence for residents.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms. Files were unorganized and needs to be sent from other facility or retrieved from facility software. Because of files being unorganized and un-filed in their proper section, a technical violation (TV) was cited. LPA reviewed client’s files for current IPP’s and surety bonds (LIC 402) a copy was handed to LPA. Type V (technical violation) has been issued to administration for R1, R2, and R3 has incomplete files from Regional Center for IPP report and admission agreement. LPA gave administrator 10 days for documents to be sent to LPA. LPA also reviewed all of the three residents funds and observed receipts and funds balanced.

Staff Files: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training. LPA conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Files were unorganized and needs to be sent from other facility or facility software. Because of files being unorganized and placed in their proper section, a technical violation (TV) was cited.
Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMBITIONS - ROSE HOUSE	FACILITY NUMBER: 197608472
	VISIT DATE: 12/14/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Medications: Medication and Medication Records (MMR) were review for proper documentation. Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies for hot bathroom water measure at 140 degrees Fahrenheit, observed during the visit. Therefore, a type A violation was cited. Exit interview conducted, appeal rights and a copy of the report issued.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/14/2023 03:40 PM - It Cannot Be Edited

Created By: Leslie Ngo-Castaneda On 12/14/2023 at 03:25 PM

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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMBITIONS - ROSE HOUSE	FACILITY NUMBER: 197608472
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/18/2023
	Plan of Correction
1 2 3 4	Water should be measure at 105-120 degrees Fahrenheit.

Type A

Section Cited

CCR

80088(e)(2)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (2) Taps delivering water at 125 degrees F (51.6 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/18/2023
	Plan of Correction
1 2 3 4	Please put a warning sign for regarding hot water.

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:

Nichelle Gillyard

LICENSING EVALUATOR NAME:

Leslie Ngo-Castaneda

LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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