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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608677
Report Date: 05/10/2022
Date Signed: 05/10/2022 02:27:16 PM

Document Has Been Signed on 05/10/2022 02:27 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 1FACILITY NUMBER:
197608677
ADMINISTRATOR:JESUS SANTANAFACILITY TYPE:
735
ADDRESS:2814 W VERDUGO AVETELEPHONE:
(818) 562-7246
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 4CENSUS: 3DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:54 AM
MET WITH:Zuleyma Osorio, administrator TIME COMPLETED:
02:35 PM
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On 5/10/22 at 11:54 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met S1 and explained the reason for the visit. LPA and S1 toured the facility together. Administrator Zuleyma Osorio arrived at 1:01 p.m.,and assisted with the rest of the visit.

Facility is licensed to serve 4 clients between the ages 18-59. 4 of which shall be non- ambulatory of which 1 may be bedridden. The facility is a single-story building in a residential area, with a commercial kitchen, dining room, living room, 4 bedrooms, 2 bathroom, office space, backyard with ample shaded area and a garage. All clients receive case management services provided by Frank D. Lanterman Regional Center. Restricted health condition care plan has been reviewed for R1. Fire extinguisher observed in office space and in dinning room. There are smoke detectors/ Carbon monoxide located throughout the facility, tested and operational.

LPAs discussed infection control practices with administrator, toured the facility inside and out, reviewed food supply, staff files, and resident medications.


Report continued on 809c
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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 1
FACILITY NUMBER: 197608677
VISIT DATE: 05/10/2022
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Bedrooms 1-4 have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. LPA toured the kitchen and observed 7 days of perishables and 2 days nonperishable. All sharps are locked and secured. Passageways and exits are free of obstruction. The front and backyard are well maintained. Bathrooms 1-2 are clean and have the required grab bars and skid matts. The hot water temperature measured at 105- 107.3 degrees F. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. LPA and LVN (S2) reviewed medications for all residents and observed medications given as prescribed. Staff file reviewed to have required background and health screening. Infection control signs posted through out the facility. During file review LPA observed administrator certificate #6034248735 expired 4/13/2021. Administrator stated that they are in the process of finishing 40 hours. LPA observed 30 days supply of PPE's. Last emergency disaster drill conducted 4/27/22.

Pursuant to Title 22 code of regulations, the following deficiencies were cited (refer to LIC 809-D): Exit Interview Conducted with administrator / Appeal Rights Provided / A Copy of the Report Issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
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Document Has Been Signed on 05/10/2022 02:27 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 05/10/2022 at 02:02 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AMBITIONS - VERDUGO 1
FACILITY NUMBER: 197608677

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064.3(d)

Administrator Recertification Requirements

To apply for recertification prior to the expiration date of the certificate, the certificate holder shall submit to the Department's Administrator Certification Section, post-marked on, or up to ninety (90) days before, the certificate expiration date:

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 in which LPA Baptiste observed administrator certificate expired on 4/13/2021. Administrator confirmed that they are in the process of completing the required hours needed for renewal, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2022
Plan of Correction
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Administrator will complete recertification process and submit everything to Sacramento by POC date. Administrator will email LPA when documents are submitted, and LPA will check current and pending list on website to clear POC.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022


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