198601016-5-2-2022-11-AS-MVAO-CF6TWM-20220607150547

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601016
Report Date: 05/02/2022
Date Signed: 05/02/2022 04:59:43 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/09/2022 and conducted by Evaluator Don Senaha

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220209085233

FACILITY NAME:	AMBITIONS - 184TH PLACE		FACILITY NUMBER:	198601016
ADMINISTRATOR:	WALKER, DEMETRA		FACILITY TYPE:	735
ADDRESS:	3902 W 184TH PL		TELEPHONE:	(310) 771-0997
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY:	4	CENSUS: 4	DATE:	05/02/2022
		UNANNOUNCED	TIME BEGAN:	12:53 PM
MET WITH:	Administrator - Demetra Walker		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident had access to a sharp object while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 02/17/2022 Licensing Program Analyst (LPA) Don Senaha initiated a complaint investigation for the allegation listed above. Today’s complaint investigation was conducted at the facility with Administrator Demetra Walker.
On 05/02/2022, LPA Don Senaha initiated a subsequent complaint investigation for the above allegation listed above. Today’s complaint investigation was conducted at the facility with Administrator Demetra Walker. The investigation today was to deliver findings and explained to Administrator Demetra Walker.

A plant inspection of the facility was conducted during both visits. LPA also requested copies of the following documents: client roster, staff roster, admission agreements, needs and service plans, function/capability assessments, facesheets, ID/Emergency information, physician reports, in service training sessions. LPA interviewed clients (C1-C3) and staff (S1-S2).

Investigation revealed:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022

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 2

Control Number 11-AS-20220209085233

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMBITIONS - 184TH PLACE	FACILITY NUMBER: 198601016
	VISIT DATE: 05/02/2022

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
26
27
28
29
30
31
32

Allegation: Resident had access to a sharp object while in care..

It is alleged that resident had access to a sharp object while in care.

Client (C1-C3) were interviewed and clients (C2-C3) were unable to discuss specific questions at the time. Client (C1) stated she likes it at the facility and gets along with everyone and stated her favorite staff is “all of them”. Client (C1, C3) stated they do help cook and prepare meals. Client (C1) stated she “grabbed knife” from staff (S2). Staff (S2) stated staff (S2) was not expecting her to grab out of staff (S2) hands while staff (S2) was cutting vegetables. Client (C1) engaged in self-injurious behavior at that time and proceeded to self-inflict injury in her abdominal area. Staff (S2) immediately deescalated the situation and staff (S1) helped secure the knife away from client (C1). Staff immediately called 911 and administered first aid to the wound. Administrator and staff (S1-S2) stated when clients are helping prepare meals, clients never have access to sharp objects while helping preparing meals. Administrator and staff (S1-S2) stated the staff always handles the sharp objects when preparing meals. LPA observed all sharps locked at the facilities during visit on 2/17/2022 and 05/02.2022. LPA reviewed documents for training for Uniform Emergency Response Training, CPI Crisis Development Model, Care welfare safety and security, behavior levels leading to a crisis, verbal and non-verbal techniques to prevent acting out behaviors and client (C1) behavior escalation training.

Based on LPA’s observation, interviews conducted and records reviews, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted with Administrator Demetra Walker, and a hard copy was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2