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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608761
Report Date: 10/09/2025
Date Signed: 10/09/2025 03:18:27 PM

Document Has Been Signed on 10/09/2025 03:18 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 - ROSE 2FACILITY NUMBER:
197608761
ADMINISTRATOR/
DIRECTOR:		NICHELLE MATHISFACILITY TYPE:
735
ADDRESS:2100 N ROSE STTELEPHONE:
(818) 561-4014
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 4CENSUS: 4DATE:
10/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Nichelle Mathis-AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced Required - 1 Year annual inspection visit. LPA met with Administrator-Nichelle Mathis and explained the purpose of the visit. The Adult Residential Facility (ARF) is licensed to serve four (4) non-ambulatory clients, of which one (1) may be bedridden. The program is vendorized through the Frank D. Lanterman Regional Center. Administrator stated she will be leaving in a few hours and designated Oseni Esther Olufunke to sign the report.

At 10:50am, LPA toured the facility and observed the following:

Required postings were observed the kitchen. Facility has several exit doors; the door in the family room is clearly marked with exit sign and is used as the main exit door. There exit door in the hallway and the front door have ramps for wheelchair. There is a fire extinguisher in the kitchen, serviced on 02/25/2025. Facility conducts quarterly fire and emergency drills; the last fire/emergency drill was conducted on 08/03/2025. The smoke detectors are interconnected. Carbon monoxide detector is battery operated. At 10:55 am the smoke and carbon monoxide detectors were tested and observed to function properly.

Common Areas: Include a dining room and living room at the entry and a family room next to the kitchen. The dining room is furnished with a table and six chairs. The living room is furnished with sofas and a cabinet with supplies of Personal Protective Equipment (PPEs). The family room is has several sofas, a television set and a piano. The floors in living room, family room and kitchen are old and need to be varnished or replaced; citation will be provided.

(Continued on 809-C)

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2025
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 - ROSE 2
FACILITY NUMBER: 197608761
VISIT DATE: 10/09/2025
NARRATIVE
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Kitchen: The appliances consisted of a refrigerator/freezer, stove, oven, dishwasher and microwave. The freezer door is loose and the microwave is old and stained; citations will be provided to replace these appliances. Knives and sharp objects are stored in locked cabinet in the garage. 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.

Bathrooms: There are two (2) full bathrooms with proper grab bars and non-skid mats. All toilets and sinks are maintained in sanitary, operating condition. Hot water temperature was measured at 109 and 109.6 degrees Fahrenheit. LPA observed two unlided trash cans in the bathrooms; citations provided.

Bedrooms: There are four (4) private bedrooms designated for clients' use. Mattresses were in good condition and there were sufficient amount of linens in each room. 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. The outdoor area was free of visible immediate hazards. Entry/exit gates and pathways were free of obstruction. The furniture consists of bench, chairs, table and umbrella, appropriate for outdoor use and was sufficient for number of clients. Garage is detached and is located in the back yard. Currently garage is being utilized for storage and office space. LPA observed a refrigerator with perishable food supplies and emergency water in the garage.

Laundry area: Laundry machines were located in the hallway. LPA observed that all toxins are stored in locked cabinets in the garage, inaccessible to clients in care.

Staff Files: Staff files were reviewed to ensure all forms and training certificates are up to date. In addition, LPA reviewed facility's Certificate of Liability Insurance (expiring on 01/01/2026).

Resident Files: A review of four out of four resident records was conducted to ensure compliance of required licensing forms.

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

Pursuant to Title 22 Division 6 of the CA Code of Regulations, violations were observed and cited during the visit. Exit Interview Conducted / A Copy of the Report provided to staff.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/09/2025 03:18 PM - It Cannot Be Edited


Created By: Nadia Shahbazian On 10/09/2025 at 02:21 PM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMBITIONS - ROSE 2
FACILITY NUMBER: 197608761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2025

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 and interview, the licensee did not comply with the section cited above in having an old, stained microwave and a freezer with a loose door, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2025
Plan of Correction
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Administrator will purchase a new microwave and a freezer/refrigerator and will send the receipts or pictures to LPA by POC date.
Type B
Section Cited
CCR
80088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.

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 having unlided trash cans in the bathrooms, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2025
Plan of Correction
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Administrator will purchase two trash cans with tightly fitted lids for both bathrooms and will send the receipts or pictures to LPA by the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Nadia Shahbazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/09/2025 03:18 PM - It Cannot Be Edited


Created By: Nadia Shahbazian On 10/09/2025 at 02:32 PM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMBITIONS - ROSE 2
FACILITY NUMBER: 197608761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
(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 having floors in the living room, family room and kitchen to be old and stained, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2025
Plan of Correction
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Administrator will ensure the floors of the living room, family room and kitchen are replaced or varnished and pictures or receipts are provided to LPA by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Nadia Shahbazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2025


LIC809 (FAS) - (06/04)
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