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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608761
Report Date: 10/13/2022
Date Signed: 10/13/2022 12:42:29 PM

Document Has Been Signed on 10/13/2022 12:42 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
GREATER LA AC/SC, 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) 561-4014
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 4CENSUS: 4DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Zuleyma Osorio AdministratorTIME COMPLETED:
12:43 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with DSP staff Olufunke Oseni and explained the purpose of the visit. Administrator Zuleyma Osorio arrived a short time later and LPA explained the purpose of the visit. 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 9/8/2022.

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.
· Each client's room is designated as a COVID-19 isolation room if needed.
· Four (4) centrally stored resident medication records were reviewed.
· All staff were observed wearing mask.
· None of the clients in care wear masks but practice social distancing guidelines
· 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.
· No deficiencies during today’s visit.
Exit interview was conducted with Administrator Zuleyma Osorio . A copy of the report was provided. (Will email report due to printer issues.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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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