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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601016
Report Date: 04/04/2024
Date Signed: 04/05/2024 10:36:06 AM

Document Has Been Signed on 04/05/2024 10:36 AM - 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:AMBITIONS - 184TH PLACEFACILITY NUMBER:
198601016
ADMINISTRATOR/
DIRECTOR:		WALKER, DEMETRAFACILITY TYPE:
735
ADDRESS:3902 W 184TH PLTELEPHONE:
(310) 771-0997
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 4CENSUS: 3DATE:
04/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:18 AM
MET WITH:Demetra WalkerTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 04/04/24, Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the (Demetra Walker, Administrator) and the purpose of today’s visit was explained. The facility is licensed to operate for (4) ambulatory developmentally disabled adults ages 18 through 59. Currently, the home has (4) and 1 is in the hospital.. The clients are Harbor Regional Center clients. None of the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices.

The facility is located in a residential neighborhood. The property consists of the following:4 client bedrooms, 2 common bathrooms, living room, kitchen, dining room, attached garage laundry room the washer and dryer and an outdoor shaded area.

LPA conducted a records review of (4) client records, (4) staff records, (4) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (4) Client Medication Records and did not observed any discrepancies at the time of visit.

At 9:30am LPA and Administrator toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed , plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105-120F ( Bathroom #110F & Bathroom #2 112F.).

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Sparkle Day
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: AMBITIONS - 184TH PLACE
FACILITY NUMBER: 198601016
VISIT DATE: 04/04/2024
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were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

During todays visit LPA did not observe any deficinecies

A copy of this report was left today with Administrator Walker.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Sparkle Day
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC809 (FAS) - (06/04)
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