<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608761
Report Date: 03/23/2023
Date Signed: 03/23/2023 02:27:41 PM

Document Has Been Signed on 03/23/2023 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,
, CA
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:
03/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Olufunke OseniTIME COMPLETED:
02:30 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
Licensing Program Analyst (LPA) Michael Cava conducted a Case Management (CM) visit to to the facility to follow up on an Incident Report received regarding Client 1 (C1) on or around March 7, 2023. LPA met with staff, Olufunke Osene and advised her of the visit. During a survey, it was reported that C1 wanted to cause injury to themselves. The purpose of the visit is to insure the health and safety of the client. The day's visit consisted of interviews and record review. Per review, and based on the information received, it was determined that C1 may have just expressed some frustration during the day the survey was made. It doesn't appear to be that C1 is a danger to self.

No deficiencies observed during the visit. Staff was advised and a copy of this report given.
SUPERVISORS NAME: Benita Yates
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
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 1