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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608610
Report Date: 03/01/2022
Date Signed: 03/01/2022 12:23:26 PM

Document Has Been Signed on 03/01/2022 12:23 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
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: 4DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator Monique TateTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced Annual visit using the infection Control Evaluation Tool. LPA arrived unannounced and met with Administrator Monique Tate ,who assist with the visit. The purpose of the visit was discussed. The facility is licensed to serve four (4) developmentally disabled ambulatory adults between the ages of 18-59. LPA observed three (3) clients at the time of this visit. One client was in the Day Program.
LPA toured the facility which includes: four (4) client bedrooms, two (2) bathrooms, living room, dining area, kitchen, laundry area near the kitchen, office and outdoor activity area. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit.

LPA and Administrator toured the facility inside and out. LPA observed that the facility does not have a swimming pool or other bodies of water. The backyard has a shaded sitting area. All indoor and outdoor passageways are free of obstruction. All bedrooms and bathrooms were inspected and observed to be clean and sanitary. Bathrooms have nonskid mats and grab bars, hot water tested within normal limits at 107.2 and 116.9 degree Fahrenheit.

The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharp objects and chemicals were inaccessible to clients. The common areas such as living room and dining room are clean and have the required furniture. The Fire extinguishers were observed fully charged. Signs are posted throughout the home to remind staff and clients to wear masks and wash hands. Medications were centrally stored and properly locked, first aid kit was checked and in order. Clients' medications were reviewed. Medications are documented and stored properly in locked kitchen cabinets.

Continue 809C


SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 - VERDUGO HOUSE 2
FACILITY NUMBER: 197608610
VISIT DATE: 03/01/2022
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LPA reviewed clients files to confirm vaccinations and to confirm emergency contacts have been updated. LPA reviewed staff files and confirmed all staff have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. A copy of the report was provided to Administrator.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC809 (FAS) - (06/04)
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