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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608761
Report Date: 10/06/2021
Date Signed: 10/06/2021 12:35:00 PM

Document Has Been Signed on 10/06/2021 12:35 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 - ROSE 2FACILITY NUMBER:
197608761
ADMINISTRATOR:MONIQUE TATEFACILITY TYPE:
735
ADDRESS:2100 N ROSE STTELEPHONE:
(818) 562-7246
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 4CENSUS: 4DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Darlene Williams, AdministrationTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with DSP staff and explained the purpose of the visit. Administrator Zuleyma Osorio and Program Supervisor Darlene Williams arrived shortly after. There are four (4) level 4N ambulatory developmentally disabled clients ages 18-59 in the home. The facility is a single story home located in a residential neighborhood that is licensed for 4 non-ambulatory of which 1 may be bedridden. It consists of 4 client bedrooms, living room/dining room, family room, kitchen, 2 bathrooms, backyard patio area, and a detached garage. The last fire drill was conducted on 9/8/2021.

The following were observed/inspected:
  • The interior and exterior physical plant was inspected.
  • COVID-19 Infection Control Practices and signs were observed in the entrance, common areas, hallways, bathrooms and resident rooms.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Furniture was observed to be at least 6 feet apart.
  • Each client's room is designated as a COVID-19 solation room if needed.
  • Four (4) centrally stored resident medication records were reviewed.
  • All staff were observed wearing mask.
  • Due to client's disability and behaviors none of the clients in care wear masks.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A posted Emergency Disaster Plan was observed.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Staff and resident files were not reviewed during today's visit.
  • Staff (S1 & S2) do not have a Criminal Background Clearance Transfer Request.
  • The side yard by the garage had discarded furniture, mirror, and doors.
Deficiencies were cited. See LIC 809D.
Exit interview was conducted with Administrator Zuleyma Osorio and Program Supervisor Darlene Williams. A copy of the report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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 10/06/2021 12:35 PM - It Cannot Be Edited


Created By: Noemi Galarza On 10/06/2021 at 11:45 AM
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 - ROSE 2
FACILITY NUMBER: 197608761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 that the side yard by the garage had discarded furniture, mirror, and doors which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2021
Plan of Correction
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Administrator agreed to remove the discarded furniture and items and send a picture as proof of correction.
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:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/06/2021 12:35 PM - It Cannot Be Edited


Created By: Noemi Galarza On 10/06/2021 at 11:56 AM
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 - ROSE 2
FACILITY NUMBER: 197608761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(f)(1)
(f) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from TrustLine to a state licensed facility by providing the following documents to the Department: (1) A signed Criminal Background Clearance Transfer Request, LIC 9182 (Rev. 4/02).


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 that two staff (S1 & S2) are not associated to the facility; which poses an immediate health, safety or personal rights risk to persons in care.

POC Due Date: 10/07/2021
Plan of Correction
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Licensee shall complete a criminal record transfer request for staff (S1 & S2) by tomorrow. Submit proof of correction.
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:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2021


LIC809 (FAS) - (06/04)
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