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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608761
Report Date: 06/26/2024
Date Signed: 06/26/2024 06:32:36 PM

Document Has Been Signed on 06/26/2024 06:32 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AMBITIONS - ROSE 2FACILITY NUMBER:
197608761
ADMINISTRATOR/
DIRECTOR:		MONIQUE TATEFACILITY TYPE:
735
ADDRESS:2100 N ROSE STTELEPHONE:
(818) 561-4014
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 4CENSUS: 3DATE:
06/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Patricia Valdez, Staff TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Panushkina conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20240620111602. LPA met with Staff #1 (S1) who granted access to facility. The Administrator was contacted and LPA was informed that she's cannot come to the facility.

During the visit, LPA was informed that S1 have been working at this facility for two (2) months. However, LPA reviewed Licensing Information System (LIS) and did not observe S1 being associated with the facility.

Per the California Code of Regulations, deficiency is cited and noted on LIC809-D.

Exit interview conducted, appeal rights and copy of report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2024
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 2
Document Has Been Signed on 06/26/2024 06:32 PM - It Cannot Be Edited


Created By: Angela Panushkina On 06/26/2024 at 02:02 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: 06/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/28/2024
Section Cited
CCR
80019(e)(3)

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Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code... ...shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance...
This requirement is not met as evidenced by
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Licensee agreed to complete S1's fingerprints and associate the staff to the facility. Copy of proof will be submitted to LPA by POC date.

Civil penalty assessed.
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Based on interview and record review, the licensee did not comply with the section cited above by having S1 working at this facility for two (2) months without fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.
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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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024


LIC809 (FAS) - (06/04)
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