198601001-12-4-2023-11-AS-EGOZ-CY7UP3-20231204144452

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601001
Report Date: 12/04/2023
Date Signed: 12/04/2023 02:45:00 PM

Document Has Been Signed on 12/04/2023 02:45 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	AMBITIONS - 171ST STREET		FACILITY NUMBER:	198601001
ADMINISTRATOR:	EDWARDS, DARREN		FACILITY TYPE:	735
ADDRESS:	3939 W 171ST ST		TELEPHONE:	(310) 532-4781
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY: 4		CENSUS: 4	DATE:	12/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:44 AM
MET WITH:	Tanisha McCall		TIME COMPLETED:	02:45 PM

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On 12/03/23, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Tanisha McCall and explained the purpose of today’s visit. LPA was granted entry to this facility. The facility is licensed to operate for four (4) developmentally disabled adults ages 18-59. Ambulatory only.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client bedrooms, two (2) bathrooms, living room, kitchen, dining room, outdoor shaded area, and an indoor and outdoor activity area. There is an attached garage in which there is an office space and the washer and dryer are in.

LPA toured the physical plant with house Administrator Tanisha McCall. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. The bathrooms were found to be within Title 22 regulation. Water temperature properly measured between 105F-120F. A comfortable temperature was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. Fire extinguishers are fully charged, and smoke detectors combined with carbon monoxide are operable. A review of Medication Administration Records and Fire Drill are maintained and in order. The last fire drill was conducted on 11/20/23.

Continued on LIC 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/04/2023

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD.

No deficiencies were cited at the time of this visit.

An exit interview was conducted, and a copy of this report along with appeal rights was provided to Administrator Tanisha McCall.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC809 (FAS) - (06/04)

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