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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608677
Report Date: 05/06/2025
Date Signed: 05/06/2025 04:53:21 PM

Document Has Been Signed on 05/06/2025 04:53 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AMBITIONS - VERDUGO 1FACILITY NUMBER:
197608677
ADMINISTRATOR/
DIRECTOR:		RFACILITY TYPE:
735
ADDRESS:2814 W VERDUGO AVETELEPHONE:
(818) 562-7246
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 4CENSUS: 3DATE:
05/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Zinnia San Pedro - LVN/DSP I and IITIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced Required - 1 Year annual inspection visit. At 11:00 am LPA spoke with Program Manager-Letica Woods and explained the purpose of the visit. The Program Manager is unable to visit the facility but she designated Zinnia San Pedro-LVN/DSP I and II to sign the report. The facility is licensed for four (4) non-ambulatory adults, one (1) of whom may be bedridden. Current census is three (3) ambulatory clients. The program is vendorized through the Frank D. Lanterman Regional Center. The facility is a home located in a residential area, it consists of four (4) client bedrooms, two (2) bathrooms, living room, dining room, kitchen, laundry area and a detached garage.

At 11:50am, LPA toured the facility and observed the following:

Required postings were observed in the office area, immediately to the right side of the entry door. Facility has several exit doors; the front entry is the main exit door and the secondary exit is located in the dining room. There are two fire extinguishers, one in the dining room, one in the office area. Both fire extinguishers were serviced on 01/20/2025. Facility conducts monthly fire and safety drills, the last safety drill was conducted on 04/03/2025. The physical plant appeared clean, sanitary and comfortable with no visible immediate hazards.

Common Areas: Include a living room and a dining room. The dining room is furnished with a table and six chairs. The living room has sofas, appropriate for the number of clients. Television set was observed in the living room, along with cabinets containing art supplies and games. The dual smoke alarms and carbon monoxide detectors are interconnected. At 11:55 am the smoke/carbon monoxide alarms were tested and observed to function properly.

(Continued on 809C-1)

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMBITIONS - VERDUGO 1
FACILITY NUMBER: 197608677
VISIT DATE: 05/06/2025
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Kitchen: The kitchen appliances consisted of a refrigerator, stove, dishwasher and microwave and all the fixtures were observed to be functional. Knives, cutlery and sharp objects are stored in locked kitchen cabinets. The cleaning supplies were stored locked in a cabinet underneath the sink. LPA found a sufficient supply of perishable foods (2 days) and non-perishable food (7 days) supplies, with sufficient amount of dishes for number of clients. All foods in containers were observed to be labeled and dated and stored in the refrigerator.

Laundry area: Laundry machines were located across bedroom #2. All toxins are stored in a locked cabinet above the machines and were inaccessible to clients in care.

Bathrooms: There are two (2) full bathrooms, one (1) for staff and one (1) designated for residents’ use. All toilets and sinks are maintained in sanitary, operating condition. LPA observed proper grab bars and non-skid mats in both bathrooms. Hot water temperature in residents' bathroom was measured at 107.4 degrees Fahrenheit.

Bedrooms: There are four (4) private bedrooms designated for clients' use. All client rooms were checked. Mattresses were in good condition and there were sufficient amount of linens in each room. Bedroom #1 is near the office area, by the front door. Bedrooms #2, #3 and #4 were located side by side. LPA observed a bed with half bed rail in bedroom# 2 but the bedroom is currently vacant, therefore there is no need for physician's order. All of the bedrooms were properly furnished with appropriate chairs, beddings, closets/chest drawers with sufficient lighting.

Surrounding grounds: No bodies of water were observed at the facility. A detached garage was observed in the backyard; currently the garage is used as storage and extra sitting area. Entry/exit gates and pathways were free of obstruction. The outdoor area was free of visible immediate hazards. The furniture consists of a bench, chairs, table and umbrella, appropriate for outdoor use and was sufficient for number of clients.

(Continued on 809C-2)

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMBITIONS - VERDUGO 1
FACILITY NUMBER: 197608677
VISIT DATE: 05/06/2025
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Resident Files: A review of resident records was conducted to ensure compliance of required licensing forms. Medications records for residents were also verified for accuracy of administration based on physician orders.

Medications: LPA observed a locked medication cabinet near the kitchen. LPA compared and counted medications for three out of three residents to ensure accuracy of administration and dosage. LPA observed two complete First Aid Kits and a First Aid Manual, locked in the medication cabinet.

Staff Files: Staff files were reviewed to ensure all forms and training certificates are up to date.

Facility Files: LPA reviewed the following records but not limited to: Emergency drills, staff training, Surty Bond (effective date of 04/29/2015) and Certificate of Liability Insurance (01/01/2025-01/01/2026).

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted / A Copy of the Report provided.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC809 (FAS) - (06/04)
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