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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601449
Report Date: 10/03/2024
Date Signed: 10/07/2024 08:31:10 AM

Document Has Been Signed on 10/07/2024 08:31 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 - DOBLE AVENUEFACILITY NUMBER:
198601449
ADMINISTRATOR/
DIRECTOR:		JOHNSON, KANISHAFACILITY TYPE:
735
ADDRESS:23228 DOBLE AVETELEPHONE:
(310) 530-3044
CITY:TORRANCESTATE: CAZIP CODE:
90502
CAPACITY: 3CENSUS: 3DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:ADMINISTRATOR MICKCA GRINAGETIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 10/03/2024 at 11:30 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Ambitions Doble Avenue Facility. LPA Calderon was allowed entry into the facility by Administrator Mickca Grinage. Administrator Mickca Grinage asked infection control questions and took LPA Calderon temperature prior to entering the facility. The facility is licensed to operate for three (3) developmentally disabled adults ages 18 through 59 years. The clients are Harbor Regional Center consumers. Currently, there are three (3) residents residing in the facility, between the age of 18 and above.

LPA Calderon explained to Administrator Mickca Grinage, the purpose of the one-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Three (3) client service records, three (3) client medication records (MAR), three (3) staff records, and inspected the inside facility and outside grounds. LPA Calderon interviewed three (3) clients and three (3) staff members for visit. The facilities’ last fire drill was conducted on 08/15/2024. The one-story residential home consists of three (3) client bedrooms, two (2) client bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored or found on the premise grounds. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the garage area.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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 - DOBLE AVENUE
FACILITY NUMBER: 198601449
VISIT DATE: 10/03/2024
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and clients, sanitizing stations (Located in common areas and restrooms). LPA observed staff and clients were NOT wearing face coverings. LPA Calderon observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA Calderon advised the Administrator Mickca Grinage to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe deficiencies therefore no citations were issued at this time. Annual Licensing Fee is CURRENT. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Mickca Grinage..
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
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 - DOBLE AVENUE
FACILITY NUMBER: 198601449
VISIT DATE: 10/03/2024
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LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of client’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 106 degrees Fahrenheit; bathroom #2 hot water temperature properly measured at 105 degrees Fahrenheit. Kitchen hot water temperature properly measured at 109 degrees Fahrenheit. Facility one (1) Carbon Monoxide and five (5) Smoke Detectors hard wired and connected were tested and are working properly. The facility one (1) Fire Extinguisher was checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. The facility has a working landline telephone. All toxins and knifes are locked/secured and inaccessible to clients. Medications are centrally stored and in a locked storage cabinet. Facility one (1) first aid kits is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to clients. Three (3) client files were reviewed and found to be complete. LPA Calderon reviewed three (3) resident medications (MAR) and they were all found to be administered according to doctor's orders. Three (3) staff files were checked and have the required documents. LPA Calderon noted the Administrator Mickca Grinage Certification # 6071892735 expiration date of 09/11/2026 was valid at time of inspection. The facility does handle client's money/cash resources and Surety bond is needed. Western Surety Company #61155727 for $1000.00 dollars is valid at time of inspection. Commercial General Liability Policy #ACP3049558980 policy period from 01/01/2024 to 01/01/2025 underwritten by Nationwide Mutual Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. Administrator Mickca Grinage to email LPA Calderon a full copy of the commercial insurance policy including all endorsements no later than 10/15/2024. All the required documents are posted in the facility in a clearly visible area.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC809 (FAS) - (06/04)
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