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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601449
Report Date: 10/02/2024
Date Signed: 12/03/2024 11:19:16 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/11/2024 and conducted by Evaluator David Espana
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240911125259
FACILITY NAME:AMBITIONS - DOBLE AVENUEFACILITY NUMBER:
198601449
ADMINISTRATOR:JOHNSON, KANISHAFACILITY TYPE:
735
ADDRESS:23228 DOBLE AVETELEPHONE:
(310) 530-3044
CITY:TORRANCESTATE: CAZIP CODE:
90502
CAPACITY:3CENSUS: 3DATE:
10/02/2024
UNANNOUNCEDTIME BEGAN:
02:44 PM
MET WITH:Mickca Grinage, AdministratorTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Staff did not keep facility free of pests.
INVESTIGATION FINDINGS:
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** This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 10/02/2024. **On 12/03/2024 Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced complaint investigation Subsequent visit for the allegation listed above. LPA met with Administrator Mickca Grinage. LPA explained the purpose of this visit is to provided an ammended copy of the LIC9099 report.

THE INVESTIGATION CONSISTED OF THE FOLLOWING:
On 09/18/2024 LPA España conducted a tour of facility plant; reviewed records for staff, clients, client roster, staff roster, and made facility observations. Additionally, requested copies and reviewed records of pest control program records; pesticide use records; maintenance logs; incident reports; staff training records; corrective action plans and compliance audits. LPA España interviewed Staff 1-Staff 4 (S1-S4). LPA España attempted to interview Client 1-Client 3 (C1-C3) at the time of visit.
LIC 9099s (cont)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
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-20240911125259
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 - DOBLE AVENUE
FACILITY NUMBER: 198601449
VISIT DATE: 10/02/2024
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Staff did not keep facility free of pests.
On 09/18/2024, Licensing Program Analyst (LPA) David España interviewed 4 staff members (S1-S4). LPA España attempted to interview C1-C3. LPA España interviewed Staff 1-Staff 4 (S1-S4) who denied the presence of bedbugs. On 09/18/2024, LPA España, accompanied by the facility administrator, inspected rooms 1, 2, and 3. On 09/18/2024, LPA España observed presence of roaches in the dining room area and noted the presence of two bait box traps. On 09/18/2024, LPA España reviewed record facility.

On 09/20/2024 LPA España received an invoice from the Bed bug American Structural Pest Control West for a comprehensive bedbug treatment of the entire home, which was conducted on September 20, 2024. On 09/20/2024, LPA España spoke to W1, from American Structural Pest Control West, who stated that on 09/20/2024, bed bugs were found at the facility, and on 09/20/2024 a treatment was completed.

Based on LPA observations. interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited. Exit Interview Conducted/Appeal Rights and a copy of this report has been issued (See LIC9099-D) to Administrator, Mickca Grinage, and a copy of this report was provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20240911125259
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 - DOBLE AVENUE
FACILITY NUMBER: 198601449
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2024
Section Cited
CCR
80087(a)(1)
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80087(a)(1)Buildings and Grounds The facility shall be clean, safe, sanitary and in good repair...and well-being of clients, employees and visitors. (1) The licensee shall take measures... free of...other insects.
This requirement is not met as evidenced by:
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Administrator agrees to review regulation 80087(a)(1) Buildings and Grounds and submit to LPA by the POC due date a written statement that indicates that the Administrator has read and understands the regulation above.
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On September 19, 2024, at 2:00 pm, LPA España spoke with W1, who confirmed that facility waw infested with bedbugs, which presents a personal rights risk to resident in care.
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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.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3