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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608761
Report Date: 01/07/2025
Date Signed: 01/07/2025 04:52:17 PM

Document Has Been Signed on 01/07/2025 04:52 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:		MONIQUE TATEFACILITY TYPE:
735
ADDRESS:2100 N ROSE STTELEPHONE:
(818) 561-4014
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 4CENSUS: 2DATE:
01/07/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:12 PM
MET WITH:Program Manager/Administrator Designee Leticia Woods & Direct Support Professional (DSP) Celeste BrownTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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This case management visit was conducted in conjunction with Complaint investigation to address the deficiencies unrelated to the complaint #31-AS-20240222132032.
During initial complaint visit on 02/29/2024, LPA Alvizar-Ettima noted the following Title 22 deficiencies.

1. During inspection LPA observed broken front window.

2. CCLD was not informed about the incident involving Client (C1) & Staff #1 (S1).

3. The Administrator is out on leave and no notification was provided to inform who is assisting the Administrator.



At the time of this visit the broke window was fixed and LPA advised the Administrators designee to ensure that physical plant is always in good repair. No citations will be issued regarding physical plant.
Based on the information obtained during initial visit, the following citations were issued and recorded on LIC809D.

Exit interview was conducted and a copy of report was issued. Administrator designee granted authorization to DSP, Brown to sign the report because she had attend a meeting away from this facility.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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 01/07/2025 04:52 PM - It Cannot Be Edited


Created By: Antonia Alvizar-Ettima On 01/07/2025 at 04:17 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: 01/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/07/2025
Section Cited
CCR
80061(b)

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80061 Reporting Requirements. (b) Upon the occurrence, during the operation of the facility… to the CCLD within the agency's next working day ... business hours. In addition, a written report … shall be submitted to CCLD within 7 days following the occurrence of such event.
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The incident report was submitted to CCLD after initial visit. Program Manager stated that moving forward Unsunsual Incidents Reports will be submitted to the licensing office within a timely manner.
This citation is cleared during this visit.
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This requirement is not met as evidenced by. The Licensee did not ensure to submit an incident report involving resident and staff. This poses potential hazard to health safety and personal rights to clients in care.
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Type B
01/07/2025
Section Cited
CCR80064(b)

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80064 Administrator - Qualifications and Duties. (b) Each licensee shall make provision for continuing operation and carrying out of the administrator's responsibilities during any absence of the administrator.
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The Program Manager informed LPA that at this time she is assigned designee for the Administrator during their absence. This citation was cleared during this visit
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This requirement is not met as evidenced by. The Administrator was out for leave of absence and Licensee did not ensure to designate specific personnel to carrying out of Administrators responsibilities. This poses potential hazard to the health, safety, and personal rights for clients 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:Naira Margaryan
LICENSING EVALUATOR NAME:Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


LIC809 (FAS) - (06/04)
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