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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601001
Report Date: 01/11/2023
Date Signed: 01/11/2023 04:30:51 PM

Document Has Been Signed on 01/11/2023 04:30 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
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:
01/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Tanisha Mc Call AdministratorTIME COMPLETED:
04:33 PM
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LPA Randle conducted a unannounced case management visit. LPA met administrator named above to discuss an incident report/SOC 341 sent to the CCL office date of incident Dec 31, 2022. The incident occurred on Dec 31, 2022. LPA interviewed administrator Tanisha McCall and staff member who witnessed the event, both clients in reference to the incident are non-verbal. LPA observed client C1(V) and C2 (P) LPA did not observe any bruises or scratches on C1 or C2, stiches where removed from C1 per administrator and C1 has returned to attending his day program. C2 has received behavior intervention assistance per program.

Tanisha Mc Call Administrator provided LPA with copies of all required paperwork.

No citations issued at this time.

Exit interview conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2023
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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