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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602113
Report Date: 08/30/2023
Date Signed: 08/30/2023 03:30:40 PM

Document Has Been Signed on 08/30/2023 03:30 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: 3DATE:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:AdministratorBaltazar Cornejo TIME COMPLETED:
03:45 PM
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On 8/30/23 at 12:15 p.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Ambitions Hedda Street. Upon arrival LPA was greeted by Direct Support Professional (DSP) Brittany Dinnon who contacted the Administrator, Baltazar Cornejo, at 12:30 p.m. to assist with today's visit. This home is licensed to serve ages 18 through 59. Three (3) ambulatory only. The is a level 4 home and the vendor is Harbor Regional Center. There were (1) clients in care during the time of this visit, the other (2) clients were visiting family or hospitalized. The last emergency disaster/fire drill was conducted on 8/22/2023. The Administrator Certificate expired on 12/08/2021 #6054422735. The administrator stated the renewal was submitted in March. LPA searched the pending and active list for administration certification was unable to confirm certification. The administrator was able to show proof of a check and 40 completed hours submitter to Sacramento. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (2) staff files, (3) client files, medications, and medication administration records for (3) clients and P&I.

This home contains 3 bedrooms, 2 bathrooms, living room, living room/dining room, office, kitchen, and an attached garage. LPA toured the physical plant with the Administrator. and observed all (3) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 106.7*F-111.3*F. The smoke detectors were battery operated and individually tested and observed to be working properly. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (2) fire extinguishers located in living room and Hallway fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked underneath kitchen sink with cleaning agents and toxins. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines.
(Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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
Document Has Been Signed on 08/30/2023 03:30 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 08/30/2023 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AMBITIONS - HEDDA STREET
FACILITY NUMBER: 198602113

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(c)
Fixtures, Furniture, Equipment, and Supplies
(c) Fireplaces and open-faced heaters shall be inaccessible to clients to ensure protection of the clients' safety.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 fireplace was observe without a cover, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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The administartor will ensure fireplace is inaccessible to clients and send photo proof to CCLD by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023


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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: AMBITIONS - HEDDA STREET
FACILITY NUMBER: 198602113
VISIT DATE: 08/30/2023
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The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use. The garage contained a working washer and dryer, with cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, PPEs, and toxins and cleaning agents stored locked and inaccessible to the clients.

In addition, a non-working fireplace observed without cover screen and accessible to the clients. LPA took photo proof of the fireplace.

The following Deficiencies were cited on the LIC809D under Title 22 California Code of Regulations. Exit interview conducted with Baltazar Cornejo, Administrator, a copy of this report was provided, and Appeal rights given.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC809 (FAS) - (06/04)
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