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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608610
Report Date: 09/14/2023
Date Signed: 09/14/2023 03:49:15 PM


Document Has Been Signed on 09/14/2023 03:49 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
Lookup Error,
, CA



FACILITY NAME:AMBITIONS - VERDUGO HOUSE 2FACILITY NUMBER:
197608610
ADMINISTRATOR:LUCY KECHEDJIANFACILITY TYPE:
735
ADDRESS:3206 W VERDUGO BLVDTELEPHONE:
(818) 562-7794
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:4CENSUS: DATE:
09/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Saul Funes, DSP2TIME COMPLETED:
04:18 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez made unannounced visit. LPA met with facility DSP2 Saul Funes and explained the purpose of the visit. LPA contacted Letica Woods, Program Manager, via phone and LPA read report to Ms. Woods. Ms. Woods authorized DSP2 Saul Funes to sign reports.

LPA Lopez made visit to deliver citation to facility for failure to report incidents.

The following incidents where not reported to the department:

1) December 2021, 2 DSP witnessed two other DSP grab clients arms forcefully.

2) March 22 2022, 2 Ambitions Verdugo House 2, DSP witnessed another DSP roughly hit another client

3) March 2022, An Ambitions Verdugo House 2, DSP witnessed another DSP hit client in stomach.

4) April 2022, at approximately 3:00PM, Ambitions Verdugo House 2, 2 DSP witnessed another DSP punch clients in the stomach.

5) October 2021, Ambitions Verdugo House 2, DSP brandished a knife threatening client in care.

The failure to report these incidents is in clear violation of Title 22 Regulations and poses a Health and Safety hazard to clients in care.

Deficiencies cited on 809D, copy of report provided along with Appeal
Rights.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/14/2023 03:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA


FACILITY NAME: AMBITIONS - VERDUGO HOUSE 2
FACILITY NUMBER: 197608610

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/21/2023
Section Cited
CCR
80061(b)(1)(e)

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80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) ........ next working day during its normal business hours.(1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
The requirement is not met as evidenced by:
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Administrator will provide the 5 missing incident reports to LPA in addition to training of all staff on reporting requirements and send proof to LPA by POC date.
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There were 5 incidents that were not reported by the facility to the department.
Incidents not reported to the department include:
1) December 2021 2 DSP witness two other DSP grab clients arms forcefully.

2) March 22 2022 two Verdugo house 2 staff witness another DSP roughly hit another client.

3) March 2022, An Ambitions Verdugo house 2 DSP witness another DSP hit client in stomach.

4) April 2022, on a Saturday around 3pm Ambitions Verdugo 2 staff witness another staff punch clients in the stomach.

5) October 2021 Staff brandished a knife threatening clients.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
LIC809 (FAS) - (06/04)
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