197608677-5-17-2024-31-AS-JGTN-D5D3PN-20240517182548

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608677
Report Date: 05/17/2024
Date Signed: 05/17/2024 06:25:59 PM

Document Has Been Signed on 05/17/2024 06:25 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	AMBITIONS - VERDUGO 1		FACILITY NUMBER:	197608677
ADMINISTRATOR/ DIRECTOR:	JESUS SANTANA		FACILITY TYPE:	735
ADDRESS:	2814 W VERDUGO AVE		TELEPHONE:	(818) 562-7246
CITY:	BURBANK	STATE: CA	ZIP CODE:	91505
CAPACITY: 4		CENSUS: 3	DATE:	05/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:25 PM
MET WITH:	Olawumi Robinson - LVN		TIME VISIT/ INSPECTION COMPLETED:	06:30 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

An unannounced Required One (1) year visit was conducted on this day by Licensing Program Analyst (LPA) Gary Tan. LPA initially met with staff Olawumi Robinson who called the administrator Nichelle Mathis and designated Ms. Robinson to sign the report. Purpose of the visit is stated. This is a Lanterman Regional Center vendored facility Specialized Level.

LPA conducted physical plant tour inside and out at 3:34 PM. During the tour, LPA observed that the facility has four (4) bedrooms and two (2) bathrooms. There is no body of water in the facility. The facility is fire cleared for four (4) non-ambulatory residents, one of which may be bedridden.

The front door is the main entrance being utilized at the facility but there is another door parallel to the main door leading immediately to the dining area where the sign in sheet and screening station is located. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Plan.

All trash cans were observed to be with cover. The facility has a designated visitors' area at the front yard. The facility has sufficient stock of PPE in the storage

Bedrooms were toured and observed to be clean and appropriately furnished.

Bathrooms were observed to be clean, sanitary and with necessary supplies. Hot water temperature measured at range of 107.7°F.

(continued on LIC 809-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: AMBITIONS - VERDUGO 1	FACILITY NUMBER: 197608677
	VISIT DATE: 05/17/2024

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

Physical plant was checked for cleanliness and condition. Facility was observed to be in good repair and clean during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area is observed to be clean and sanitary. All disinfectants, cleaning solutions are kept in locked cabinet below the sink.
Food. The facility is observed to have sufficient food supply for clients. Temperature of facility wall thermostat was set at 74.0°F and observed to be within the required range.
Fire extinguisher was observed to be located by the kitchen. Extinguisher was observed to be operable and last bought on 01/12/24. Fire alarms are hardwired and interconnected and observed to be operational. There is a carbon monoxide detector installed in the facility.
Medications were observed to be locked, inaccessible and stored in the cabinet near the dining room. There was a complete first aid kit located in the supply room inside the staff room closet. Knives and sharps are locked and secured in the kitchen drawer.
Garage is detached to the house and observed to be no hazardous materials being kept. Laundry room is located along the bedrooms' hallway. Laundry detergents and other cleaning agent are kept in the locked cabinet on top of the washing and machine. Garage is also used as PPE, emergency supplies and tools and old equipment storage.
Client records. Three (3) client records were reviewed. Clients’ record appeared to be complete and current. Staff records were also reviewed. Four (4) staff records were reviewed, they all have criminal record clearances and associated to this facility. Current training and first aid observed for staff on duty. Administrator's certificate was observed to be current.

Disaster drill was last conducted on 03/15/24. Required posting observed in facility (complaint hot line poster, personal rights, etc).

There was no health and safety hazard observed during the day of inspection.

Exit interview conducted and a copy of this report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2