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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608610
Report Date: 04/27/2024
Date Signed: 04/27/2024 03:25:15 PM

Document Has Been Signed on 04/27/2024 03:25 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/
DIRECTOR:		LUCY KECHEDJIANFACILITY TYPE:
735
ADDRESS:3206 W VERDUGO BLVDTELEPHONE:
(818) 562-7794
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 4CENSUS: 4DATE:
04/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:27 PM
MET WITH:Maria Molina/StaffTIME VISIT/
INSPECTION COMPLETED:
03:24 PM
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On 4/27/24 Licensing Program Analysts (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPAs met with Maria Molina/Staff and the purpose of today’s visit was explained. The facility is licensed to operate for (4) ambulatory developmentally disabled or Mentally Ill adults ages 18 through 59 ambulatories only. Currently, the home has (4) clients. The clients are from: Frank D. Lanterman Regional Center. None of the clients have Restricted Health Care Conditions, and none utilizes postural support or protective devices. Staff to client ratio is 3:4.

The facility is a home located on a residential area, it consists of four (4) client bedrooms, two (2) bathrooms, living room, dining area, kitchen, laundry area near the kitchen, office, and outdoor activity area.

LPA Iniguez and administrator toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105F°-120F° degrees (Kitchen 118.8F°, Bathroom #1 116.8°F).

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2024
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 04/27/2024 03:25 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 04/27/2024 at 03:15 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
,
, CA

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(4)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 80019.1(r), unless, upon request for the transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having S#2 associated at current facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2024
Plan of Correction
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Licensee will ensure all staff is associated at the facility at all times. As plan of correction, administrator will associate S#2 and will send proof of correction to LPA via email before POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2024


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
Lookup Error,
, CA
FACILITY NAME: AMBITIONS - VERDUGO HOUSE 2
FACILITY NUMBER: 197608610
VISIT DATE: 04/27/2024
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LPA Iniguez and Cross observed the facility clean, sanitary, and appropriately furnished at the time of the visit. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. Carbon monoxide/Smoke detectors were observed and operational. Fire extinguishers were fully charged, toxins and knives were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last facility disaster drill was:1/29/24. LPA reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. A total of (2) clients records and (2) staff records and (2) Medication Administration Records (MARS) LPAs found no discrepancies at the time of the visit. Facility licensee fees are current.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-S#2 not associated at facility

Civil Penalty Served: S#2 not associated at current facility.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Maria Molina /Staff.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2024
LIC809 (FAS) - (06/04)
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