198601449-9-25-2022-11-AS-EDAT-CJLW2N-20220925165437

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601449
Report Date: 09/25/2022
Date Signed: 09/25/2022 04:54:52 PM

Document Has Been Signed on 09/25/2022 04:54 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	AMBITIONS - DOBLE AVENUE		FACILITY NUMBER:	198601449
ADMINISTRATOR:	JOHNSON, KANISHA		FACILITY TYPE:	735
ADDRESS:	23228 DOBLE AVE		TELEPHONE:	(310) 530-3044
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90502
CAPACITY: 3		CENSUS: 3	DATE:	09/25/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:01 PM
MET WITH:	Rosemary Ezeani		TIME COMPLETED:	04:53 PM

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	On 08/13/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with the caregiver Rosemary Ezeani. LPA explained the purpose of today’s visit. Ezeani contacted administrator Vanessa Quirarte by telephone and was unable to be at the facility. The facility is licensed to operate for three (3) developmentally disable adults ages 18 through 59 years. The clients are Harbor Regional Center consumers. The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) client's rooms, two (2) common bathrooms, a living area, dining area, kitchen, and outside area. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in place, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available at the visit. Bathrooms were operational condition. The water temperature measured 105.3 degrees F. A comfortable temperature of 81 degrees was maintained in the facility. LPA observed the facility to be furnished at the time of visit. Storage areas for personal hygiene were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. The facility maintains a Certificate of Liability Insurance in effect from 01/01/2022-01/01/2023. A review of Medication Administration Records (MAR) was maintained in order and accurate. Evaluation Report continues on LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2022

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMBITIONS - DOBLE AVENUE	FACILITY NUMBER: 198601449
	VISIT DATE: 09/25/2022

NARRATIVE

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DEFICIENCY:
During a health and safety inspection, LPA identified at 2:34 pm a cabinet inside the garage with disinfectant and hazardous cleaning solutions was unlocked and accessible to clients in care.

As a result of time constraints and the administrator not available during this visit, an annual continuation is necessary to continue a health and safety inspection of smoke detectors and carbon monoxide, review staff vaccination records, and conduct Infection Control questionnaires.

An exit interview is conducted with Rosemary Ezeani. A copy of this report is provided along with the appeal rights.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/25/2022 04:54 PM - It Cannot Be Edited

Created By: Ernand Dabuet On 09/25/2022 at 03:17 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: AMBITIONS - DOBLE AVENUE	FACILITY NUMBER: 198601449
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA identified an unlocked cabinet inside the garage with hazardous disenfectant or/cleaning solutions. This violaiton which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/26/2022
	Plan of Correction
1 2 3 4	The licensee will adhere to Title 22 regulations 80087. The licensee will ensure that hazardous items that pose danger to residents in care are in locked storage at all times. Proof of correction must be sent to CCLD via fax 323-981-1781 by (POC) 09/26/22. This was corrected during visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Eva M Alvarez

LICENSING EVALUATOR NAME:

Ernand Dabuet

LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2022

LIC809 (FAS) - (06/04)

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