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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601001
Report Date: 01/27/2023
Date Signed: 01/27/2023 05:12:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/24/2023 and conducted by Evaluator Jeremiah Randle
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230124143408
FACILITY NAME:AMBITIONS - 171ST STREETFACILITY NUMBER:
198601001
ADMINISTRATOR:EDWARDS, DARRENFACILITY TYPE:
735
ADDRESS:3939 W 171ST STTELEPHONE:
(310) 532-4781
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY:4CENSUS: 4DATE:
01/27/2023
UNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Tanisha Mc Call AdministratorTIME COMPLETED:
05:18 PM
ALLEGATION(S):
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Facility staff failed to provide proper supervision resulting in client sustaining an injury.
INVESTIGATION FINDINGS:
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On 1/27/2023 at 10:00a.m. Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced visit to deliver the findings for the complaint with the above allegation.LPA identified himself and discussed the purpose of the visit and the elements of the allegation with Tanisha Mc Call Administrator.

Investigation Consisted the following.

LPA conducted observation of physical plant, and conducted Staff Interviews (S1-S2), Clients were not interviewed due in fact they are all nonverbal. LPA conducted a review of C1’s and C2’s Facility File, records were reviewed, LPA obtained copies of pertinent documents pertaining to the allegation. LPA requested and received from the facility (Admissions Agreement, Physicians Report /Medical Records, Client Roster, Staff Roster) Needs and Services, Functional Capability Assessment, SIR’s/ staff / nursing notes if any for both Client 1(victim) and Client 2 (perpetrator) inclusive of all documents.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 11-AS-20230124143408
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMBITIONS - 171ST STREET
FACILITY NUMBER: 198601001
VISIT DATE: 01/27/2023
NARRATIVE
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Investigation Revealed the following.

Regarding Allegation: Facility staff failed to provide proper supervision resulting in client sustaining an injury.

The investigation revealed the following: Client #1 (V) was struck by Client #2 (P) on 12/31/2023 which resulted in Client #1 being taken to medical center for treatment. Client #1 injured area received stitches from the medical center and returned to the facility. Per Interviews conducted with staff 1 and 2, Client #2 head butted Client #1 quickly without reason or provocation, staff (S2) intervened immediately to redirect Client #2 (P) and provided basic first aid to Client #1(V) before transport to medical center. S1 revealed that during the time of this incident S3 was redirected to another facility to provide support as a female staff was needed to assist with a female client at an associated facility. Redirecting staff left the facility (subject of this complaint) short staffed. During this time period Client #1 sustained an injury requiring medical attention needing basic first aid from facility staff and medical attention requiring stitches.

Findings:

Based on LPA observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED



California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit Interview conduct and a copy of the appeal rights were given.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230124143408
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMBITIONS - 171ST STREET
FACILITY NUMBER: 198601001
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/27/2023
Section Cited
CCR
80078(a)
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The licensee shall provide care and supervision as necessary to meet the client's needs...


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Facility developed a plan with behaviorist and trained staff on the plan for Client #2 regarding behaviors. Administrator shall ensure that supervision is necessary to meet the client's needs, submit plan on how they will ensure clients needs are being met.
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This requirement not met based on Interviews.


adequate staffing was not available nor present to prevent client on client injury"
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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.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3