198601449-10-3-2023-11-AS-LMOA-CW9UF2-20231003153157

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601449
Report Date: 10/03/2023
Date Signed: 10/03/2023 03:32:05 PM

Document Has Been Signed on 10/03/2023 03:32 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 ASC, 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:	10/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	VANESSA QUIRARTE		TIME COMPLETED:	03:45 PM

NARRATIVE

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On 10/3/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Vanessa Quirarte. LPA explained the purpose of today’s visit.

The facility is licensed to operate for three (3) developmentally disabled 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 bedrooms, one with an ensuite bathroom, one (1) common bathroom, a living area, dining area, kitchen, outside area and a garage.

At 10:13 am, kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents.

At 10:21 am, LPA observed the client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. Client bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

At 10:24 am, outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

At 11:00 am, LPA checked the water temperature and it was measured at 113.0 degrees F. Fire drill was conducted on 9/6/2023.

REPORT CONTINUED IN LIC 809C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMBITIONS - DOBLE AVENUE	FACILITY NUMBER: 198601449
	VISIT DATE: 10/03/2023

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At 11:15 am, LPA observed the smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available.

At 11:55 am, LPA conducted records review and found client files are current. Medication administration records (MARs) were reviewed and found to be in compliance.

At 2:20 pm, LPA conducted additional records review and determined staff files are current. LPA conducted interview with two on-duty staff. All three clients were at day program during the visit. LPA was unable to interview the clients.

The following deficiency was observed during the inspection:

At 10:21 am, LPA Montoya observed the carpet floor in all three client bedrooms are dirty with black stains. The blinds in bedroom #3 is broken and beyond repair.

At 10:24 am, LPA observed three dirty and unsanitary buckets with accumulated garbage and empty bottles on the left side of the outdoor area of the facility.
At 10:28 am, LPA observed a broken sliding door screen is leaning on the wall at the back patio. The sliding door has no screen.

Deficiency cited under California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted and a copy of Report and Appeal Rights provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/03/2023 03:32 PM - It Cannot Be Edited

Created By: Lourdes Montoya On 10/03/2023 at 03:05 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: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. At 10:21 am, LPA Montoya observed the carpet floor in all three client bedrooms are dirty with black stains. The blinds in bedroom #3 is broken and beyond repair. The window screen in the common bathroom is broken. At 10:24 am, LPA observed three dirty and unsanitary buckets with accumulated garbage and empty bottles. At 10:28 am, LPA observed a broken sliding door screen is leaning on the wall at the patio patio. The patio has no screen. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/23/2023
	Plan of Correction
1 2 3 4	The Administrator agreed to clean the carpet and the buckets, repair the sliding door screen, and replace the blinds in bedroom #3 and the window screen in the common bathroom. The administrator shall submit the proof of corrections to CCLD via email to lourdes.montoya@dss.ca.gov.

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:

Janae Hammond

LICENSING EVALUATOR NAME:

Lourdes Montoya

LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

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