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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601001
Report Date: 09/19/2025
Date Signed: 09/19/2025 04:47:26 PM

Document Has Been Signed on 09/19/2025 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 STREETFACILITY NUMBER:
198601001
ADMINISTRATOR/
DIRECTOR:		EDWARDS, DARRENFACILITY TYPE:
735
ADDRESS:3939 W 171ST STTELEPHONE:
(310) 532-4781
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 4CENSUS: 4DATE:
09/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Tanisha McCallTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 09/19/25, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit using the CARE Inspection Tool. LPA met with Administrator, Tanisha McCall, and the purpose of today’s visit was explained. LPA was granted entry into the facility. 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 structure 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 table and chairs, and an 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, blankets, and comforters in good repair stored in client rooms. All 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
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 09/19/2025
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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 cutlery 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 table with chairs to accommodate all clients. The facility was maintained at a comfortable temperature. LPA observed all walkways and hallways in the facility 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 four (4) individuals P&I and observed they were consistent with properly documented records. LPA reviewed the files for the administrator and two (2) staff and found they contained the required documents, certification, and training. The administrator’s Administrator Certificate 7020336735 is valid till 10/24/25. LPA received and reviewed the surety bond through Wester Surety Company. 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 found the medications to be consistent with proper documentation. LPA observed all medications in their original packaging.
Safety LPA observed the smoke and carbon monoxide detectors to be fully operational. LPA observed a fully charged fire extinguisher, last serviced on 01/16/25. The last emergency drill was conducted on 08/25/25. The last Fire Prevention Inspection was conducted by Torrance Fire Department on 01/14/25. 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 observed all required posting posted throughout the facility.
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).
According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 809-D).

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

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/19/2025 04:47 PM - It Cannot Be Edited


Created By: Wendy Gibbs On 09/19/2025 at 04:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMBITIONS - 171ST STREET
FACILITY NUMBER: 198601001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed a hole in the lower part of the wall next to the garage door, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2025
Plan of Correction
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Administrator will email LPA a piciture of the fixed wall on or before the POC, to wendy.gibbs@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Eva M Alvarez
NAME OF LICENSING PROGRAM MANAGER:
Wendy Gibbs
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2025


LIC809 (FAS) - (06/04)
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