198601001-9-27-2024-11-AS-WGIS-D9HVVZ-20240927164711

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601001
Report Date: 09/27/2024
Date Signed: 09/27/2024 04:47:17 PM

Document Has Been Signed on 09/27/2024 04:47 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/ DIRECTOR:	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:	09/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:39 PM
MET WITH:	Tanisha McCall Trotter		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/27/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit using the CARE Inspection Tool. LPA met with DSP, Raquel Linares, and the purpose of today’s visit was explained. We were later joined by Administrator, Tanisha McCall (Trotter). The facility is licensed to serve four (4) developmentally disabled ambulatory adults ages 18-59. There are four (4) Individuals in placement at the facility. Physical Plant/Structure The facility is a single-story home located in a residential neighborhood. It consists of four (4) client bedrooms, two (2) bathrooms, living room, dining room, kitchen, backyard with a shaded patio with a table and chairs, and attached garage used as an office and laundry. LPA observed all walkways around the facility to be clean, clear, and free of debris, hazards, and obstruction. LPA did not observe any bodies of water on the premises. Bedrooms LPA inspected the four (4) client bedrooms and observed them to be clean and in good repair. All rooms were observed with the required furniture including bed, dresser, nightstand, and ample storage space for client’s personal belongings. LPA observed the beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an ample supply of linens, blanket, and comforters in good repair stored in client rooms. All

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

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: 09/27/2024

NARRATIVE

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bedrooms were observed with ample lighting.
Bathrooms LPA inspected all bathrooms and observed them to be within Title 22 regulations and were clean and operational. All safety handrails were secured. LPA observed showers to have non-skid mats. LPA observed an ample supply of hygiene products and towels. The water temperature in the bathrooms measured 113.7-degrees and 112.5-degress Fahrenheit.
Kitchen LPA inspected the facility kitchen and found it to be clean and sanitary. LPA observed all appliances to be operational and in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods, properly packaged, stored, and labeled. LPA observed all knives and sharps to be secured in a locked cabinet in the garage. LPA observed all cleaning and laundry supplies secured in a locked cabinet in the garage. LPA observed an ample supply of cookware, dishware, and cutleries in good repair. The water temperature in the kitchen measured 109.2-degree Fahrenheit.
Common Rooms During the time of visit, LPA observed the facility to be appropriately furnished. The living room has recliners and a couch to accommodate all clients. LPA observed games, activities and reading material available for clients. The dining room has a large rectangle table with chairs to accommodate all clients. The facility was maintained at a comfortable temperature. LPA observed all walkways and hallways in the home to be clean, clear, and free of obstructions and hazards. All rooms were observed with ample lighting.
Files LPA reviewed the files for four (4) individuals and found they contained the required documents. LPA reviewed the files for three (3) staff and found they

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

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: 09/27/2024

NARRATIVE

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contained the required documents, certification, and training. The Administrators Certificate is valid till 10/24/25. LPA observed all required posting posted throughout the facility. LPA received and reviewed the surety bond through Wester Surety Company. During facility file LPA observed the facility’s Licensing Fees are current.
Medications LPA observed all Centrally Stored Medication secured in a locked cabinet in the kitchen and are inaccessible to clients. LPA reviewed the medications for four (4) clients and the Medication Administration Record (MAR) and the found the medications to be consistent with proper documentation. LPA observed all medications in their original packaging.
Infection Control LPA observed an ample supply of hand soap and paper towels in the bathrooms. LPA observed Infection Control signs posted throughout the facility. LPA observed a 30-day supply of Personal Protective Equipment (PPE).
Safety LPA observed the smoke and carbon monoxide detectors to be fully operational. LPA observed a fully charged fire extinguisher, last serviced on 01/03/24. The last emergency drill was conducted on 07/03/24. The last Fire Prevention Inspection was conducted by Torrance Fire Department on 01/03/24. All exits are marked with an EXIT sign. LPA inspected the First Aid Kit and observed it to have the required items and a manual. The facility has a working telephone. LPA observed all emergency phone numbers and Emergency Disaster Plan available.
LPA did not observe or cite any deficiencies.
An exit interview was conducted with Administrator, Tanisha McCall, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC809 (FAS) - (06/04)

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