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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601016
Report Date: 12/10/2022
Date Signed: 12/10/2022 02:04:07 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
03/12/2021 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210312155222
FACILITY NAME:AMBITIONS - 184TH PLACEFACILITY NUMBER:
198601016
ADMINISTRATOR:WALKER, DEMETRAFACILITY TYPE:
735
ADDRESS:3902 W 184TH PLTELEPHONE:
(310) 771-0997
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY:4CENSUS: 4DATE:
12/10/2022
UNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:Demetra WalkerTIME COMPLETED:
02:17 PM
ALLEGATION(S):
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Client sustained a fracture while in care.
Staff hits a client while in care.
Staff mistreats a client while in care.
INVESTIGATION FINDINGS:
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On 12/10/22 Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint investigation for the allegations listed above. Today’s complaint investigation was conducted with Demetra Walker. The purpose of the visit was to deliver findings on the allegations.

The investigation consisted of the following: on 03/15/2021 Licensing Program Analyst (LPA) Don Senaha requested copies of the following documents: client roster, staff roster, admission agreements, needs and service plans, function/capability assessments, factsheets, ID/Emergency information, physician reports, in service training sessions for the last 6 months and all staff applications and conducted a plant inspection. On 03/16/2022 Licensing Program Analyst (LPA) Don Senaha interviewed clients 4 out of 4 clients, staff (S1-S2) and the Administrator. A plant inspection was conducted.

Evaluation Report continues LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2022
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 3
Control Number 11-AS-20210312155222
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMBITIONS - 184TH PLACE
FACILITY NUMBER: 198601016
VISIT DATE: 12/10/2022
NARRATIVE
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Investigation revealed:

Allegation: Client sustained a fracture while in care.
During the course of the investigation, LPA was unable to find any documents supporting the allegation. On March 15, 2021, LPA did not observe any concerns with clients (C1-C4). During interviews Client (C1-C2) stated they do not have any concerns with the staff. Client (C2) stated client (C2) does not recall any housemates going to the hospital for broken bones. LPA conducted interview with Administrator. Administrator stated client (C1) did not sustain any fractures while in care at the facility. Placement agency (W1) stated (W1) was unable to find any documents supporting the allegation. Primary Care Physician office (W3) stated there were no reports or visits by client (C1).

Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation.

Allegation: Staff hits a client while in care.
During the course of the investigation, LPA was unable to find any documents or evidence supporting the allegation. During the interview with clients (C1-C2) there was no concerns about staff physically harming the clients. Administrator stated no concerns about staff physically harming clients while in care. Staff (S1-S2) denied having concerns with staff physically harming clients while in care. LPA conducted an interview with placement agency (W1-W2) who stated they were unable to find evidence to support the allegation, during their investigation.

Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation.

Allegation: Staff mistreats a client while in care.
During the course of the investigation, LPA was unable to find any documents supporting the allegation. LPA conducted interviews with clients (C1-C2), Administrator, staff (S1-S2) and placement agency (W1-W2).
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20210312155222
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMBITIONS - 184TH PLACE
FACILITY NUMBER: 198601016
VISIT DATE: 12/10/2022
NARRATIVE
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During the interview with clients (C1-C2) there was no concerns that staff interact inappropriately with the clients. Administrator stated she did not witness any inappropriate staff interactions with the clients in care. Staff (S1-S2) stated staff has not witnessed any inappropriate interactions with the clients in care by staff. Placement agency (W1-W2) stated there are no concerns of any inappropriate staff interactions with clients in care.

Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegations. Although the allegations 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 allegations are Unsubstantiated.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3