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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602113
Report Date: 08/19/2021
Date Signed: 08/19/2021 04:46:13 PM

Document Has Been Signed on 08/19/2021 04:46 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:AMBITIONS - HEDDA STREETFACILITY NUMBER:
198602113
ADMINISTRATOR:LAQUALA MCKINLEYFACILITY TYPE:
735
ADDRESS:12914 HEDDA STREETTELEPHONE:
(562) 474-8418
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 3CENSUS: 2DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Eric EstradaTIME COMPLETED:
05:00 PM
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On 8/19/2021 Licensing Program Analysts (LPAs) Nina Galarza and Nune Margaryan conducted an unannounced Annual/Required 1 year inspection at Ambitions - Hedda Street and met with staff Eric Estrada and later met with administrator, Baltazar Cornejo and explained the purpose of the visit. This home is licensed to serve (3) Ambulatory, Adults age 18 to 59 with Developmental Disabilites, and have restricted health condition care plans on file, and Harbor Regional Center is the vendor. This home is located in a residential neighborhood and contains 3 bedrooms, 2 bathrooms, living room, family room, kitchen, and an attached garage. During this visit, LPA conducted a tour of the physical plant inside and outside, inspected all resident bedrooms, bathrooms, tested the hot water temperature, checked the fire extinguisher, food supply, checked medications and medication administration records and reviewed and (3) client files. There were 2 clients in care during the time of the visit. LPAs were screened for COVID-19 upon arrival. LPAs observed COVID-19 informational postings, social distancing sings on front door, front living room and kitchen.

Physical Plant: All client rooms contained required bed, mattress/box spring, linens, sheets, protectors and covers. Each Client has their own room. Closets contained sufficient storage space. Hot water temperature was 120 degrees Fahrenheit at time of visit, which meets title 22 guidelines. The hall closet contained designated linens labeled for each client. LPA observed the bathrooms to be clean and sanitary with working toilets and water faucet, shower chair, grab bars and grooming supplies. Garage contained: washer and dryer, emergency disaster supplies, continence supplies, supply of bottled water, decorations, laundry detergent, cleaning supplies and toxins are locked cabinet secured and inaccessible to the clients The staff files/client files were located in hall closet (kitchen). LPAs observed fire extinguisher was located in hallways and was up to date. The outdoor grounds were toured at approximately 2:45 p.m. and observed to be free of debris or clutter, obstructions or hazards. The backyard contained a shaded seating area accessible to the clients. Exits were marked and notifications and postings were observed: personnel report, administrator certificate, facility sketch, emergency disaster plan, emergency procedures and personal rights.

CONTINUED 809-C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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 2
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: AMBITIONS - HEDDA STREET
FACILITY NUMBER: 198602113
VISIT DATE: 08/19/2021
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Food Service: LPAs observed 2 days perishable and 7 day non-perishable food for all clients. Kitchen counters, storage areas, refrigerators and preparation areas were clean and sanitary. Dishware, utensils, cutlery, pots and pans were sufficient for food service. Knives and sharps were locked in kitchen cabinet with a magnetic lock and inaccessible to the clients.

Medications: Medications were contained in a locked cabinet in the kitchen with a magnetic lock and inaccessible to the clients. LPA reviewed medications and medication administration records (August 2021) and observed physician orders and medications were on-hand and did not observe any discrepancies.

Exit interview conducted with Administrator, Baltazar Cornejo, a copy of this report is being provided and Appeal Rights have been given.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
LIC809 (FAS) - (06/04)
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