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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601449
Report Date: 10/14/2021
Date Signed: 10/14/2021 06:48:18 PM

Document Has Been Signed on 10/14/2021 06:48 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
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:
10/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Doris Bell - AdministratorTIME COMPLETED:
12:19 PM
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On 10/14/2021, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Administrator Doris Bell/Rochelle Daniels and explained the purpose of today’s visit. The facility is licensed to operate for three (3) developmentally disabled ambulatory clients of between the ages of 18 through 59.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) clients, two (2) bathrooms, one (1) living areas, one (1) dining area, kitchen, and outside patio area with a table and an umbrella for shade. The garage is attached and includes an additional freezer and the washer and dryer.

LPA and caregiver Rosemary Ezeani toured the physical plant and was later joined by Administrator Doris Bell. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 105.4 F to 107.8 F in the bathrooms and kitchen sink. A comfortable temperature of 75 degrees was maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. There are three (3) fire extinguishers fully charge, one (1) in the kitchen and two (2) in the garage, smoke detectors and carbon monoxide were operable. A reviewed of Medication Records Administration (MAR) and observed to be maintained in order and accurate.
Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMBITIONS - DOBLE AVENUE
FACILITY NUMBER: 198601449
VISIT DATE: 10/14/2021
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

No deficiencies were cited during this inspection visit.

Advisory Notes – One (1) Technical Assistance was issued, please see LIC9102-AN.

An exit interview was conducted and a copy of this report was provided to Administrator Rochelle Daniels.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC809 (FAS) - (06/04)
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