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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601001
Report Date: 11/22/2024
Date Signed: 11/22/2024 05:25:35 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
11/14/2024 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20241114105351
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:
11/22/2024
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Tanisha McCallTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility is in disrepair.
Facility is not clean and sanitary condition.
INVESTIGATION FINDINGS:
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On 11/22/2024, the department conducted an unannounced complaint visit to the facility listed above. The department met with Administrator, Tanisha McCall, and the purpose of today’s visit was explained.

During today’s visit the department conducted a facility inspection, interviewed Staff S1-S5, interviewed Clients C1-C4, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Work Orders, Cleaning Logs, resident Individual Program Plan, resident Behavior Plan and an intention letter for the back patio.

The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
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 6
Control Number 11-AS-20241114105351
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMBITIONS - 171ST STREET
FACILITY NUMBER: 198601001
VISIT DATE: 11/22/2024
NARRATIVE
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Allegation: Facility is in disrepair.
The complaint allegation alleges that the facility is in deplorable condition.

During the facility tour, the department observed three kitchen cabinets and two drawers need repaired, the fan and microwave above the stove is not operational, dishwasher is not operational, baseboards in hallway and bathrooms need repaired, remove nails from the wall in bathroom 1 and patch holes and paint, the front gate needs repaired, paint on wall in room 1 is chipping, paint on the wall behind the toilet is chipping, the deck in the backyard is in disrepair, wall behind the dining room table is scratched and nicked, and a hole in the wall by the kitchenette. During today’s visit the department observed two (2) maintenance workers putting in new doors to Client bedrooms and repairing door jams.


During record review, the department received and reviewed Work Orders for repairs. The Work Orders are for 03/12/24 a request for kitchen cabinets to be replaced, on 04/10/24 a request regarding the front gate being down, on 04/23/24, a request for the oven button to be fixed, on 07/17/24 requesting for a new garage door frame and bedroom four (4) door frame to be replaced, on 10/07/24 request bathroom two wall needs repaired and bathroom 1 needs a new toilet seat, and on 11/15/24 a request to repair hole in living room walls. The department received and reviewed an intent letter from the owner of the building to have the the back deck removed, currently arrangements are being made with a contractor company.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20241114105351
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMBITIONS - 171ST STREET
FACILITY NUMBER: 198601001
VISIT DATE: 11/22/2024
NARRATIVE
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During interviews with Staff S1-S5, were asked if they feel the facility is in good repair, five (5) out of five (5) stated it is being worked on and getting there. Additionally, during interviews with Staff S1-S5, were asked once a Work Order is submitted how long does it take for the repair to be completed, five (5) out of five (5) stated the repairs are completed in 1 to 2 days unless a part needs to be ordered.
During an interview with Client C1, was asked if they felt the facility was in good repair, one (1) out of one (1) stated yes. Clients C2-C4, were unable to answer questions during the interview.

During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.



Allegation: Facility is not clean and sanitary condition.
The complaint allegation alleges that the facility is unclean and unsanitary with dirty air vents, cooking stains, and clouds of dust.

During the facility tour, the department observed cooking stains on the ceiling above the stove and the air vents are dusty.


During record review, the department received and reviewed Weekly Shift Duties
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20241114105351
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: AMBITIONS - 171ST STREET
FACILITY NUMBER: 198601001
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2024
Section Cited
CCR
80087(a)
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80087 Buildings 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 was not met as evidence by: Based on interviews and observation the department observed

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Administrator and maintenance were infomed of the repairs that need to be made. The Administrator will send pictures to LPA as repairs are completed and when the deck is removed before the POC due date.
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three kitchen cabinets and two drawers need repaired, the fan and microwave above the stove is not operational, dishwasher is not operational, baseboards in hallway and bathrooms need repaired where missing, remove nails from the wall in bathroom 1 and patch holes and paint, the front gate needs repaired, paint on wall in room 1 is chipping, paint on the wall behind the toilet is chipping, the deck in the backyard is in disrepair, the front gate is in disrepair, wall behind the dining room table is scratched and nicked, and a hole in the wall by the kitchenette. During today’s visit the department observed two (2) maintenance workers putting in new doors to Client bedrooms and repairing door jams.
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Type B
12/22/2024
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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Adinistrator will have staff clean the air vent and the ceiling in the kitchen will be repainted. Adminitrator stated they have tried to clean the cooking stains and they have remained. Administrator will email pictures of the painted ceiling and cleaned vent before POC due date.
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This requirement was not met as evidence by: Based on interviews and observation the department observed cooking stains on the ceiling of the kitchen and duct in the air vent in the hallway.
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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: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20241114105351
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMBITIONS - 171ST STREET
FACILITY NUMBER: 198601001
VISIT DATE: 11/22/2024
NARRATIVE
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that include cleaning. The department observed each shift has different responsibilities. The AM shift is responsible for ensuring dishes are cleaned and put away, empty trash, sweep, vacuum, clean bathrooms, clean Client bedrooms, make beds, clean patio furniture, pick up yard, wash bedding, wash linens, clean mattress covers, and wash, fold, and put laundry away. The PM shift is responsible for ensuring dishes are clean and put away, empty trash, clean counters, clean appliances, sweep, mop, and clean Client rooms. The NOC shift is responsible for ensuring dishes are clean and put away, wipe counter, clean appliances, wipe cabinet doors, clean stove, clean oven, clean microwave, clean refrigerator, empty trash, clean toilets, clean sinks, clean showers, sweep floors, mop floors, dust surfaces, wash Clients clothes, wash bedding wash towels, fold and put laundry away. Each item is signed off by the staff who performed the task.
During interviews with Staff S1-S5, were asked how often the facility is cleaned, five (5) out of five (5) stated the facility is cleaned daily, multiple times. Additionally, during interviews with Staff S1-S5, were asked if they felt the facility is clean and sanitary, four (4) out of five (5) stated yes, they believe the facility is clean and sanitary.
During an interview with Client C1, was asked if he felt the facility was clean and sanitary, C1 stated yes. Additionally, C1 was asked if their room is cleaned regularly, C1 stated yes.
During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 11-AS-20241114105351
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMBITIONS - 171ST STREET
FACILITY NUMBER: 198601001
VISIT DATE: 11/22/2024
NARRATIVE
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record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.

An exit interview was conducted with Administrator, Taneshia McCall, and a copy of this report and the Appeals Rights were provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6