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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602113
Report Date: 11/21/2023
Date Signed: 11/21/2023 02:22:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/17/2023 and conducted by Evaluator Jewel Baptiste
COMPLAINT CONTROL NUMBER: 28-AS-20231117131132
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:
11/21/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Baltazor CornejoTIME COMPLETED:
02:37 PM
ALLEGATION(S):
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Facility is unsanitary
Facility is malodorous
Facility has an infestation of insects
Facility is in disrepair
INVESTIGATION FINDINGS:
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On 11/21/2023 at 10:00 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an initial complaint visit to investigate the above listed allegations. Upon arrival LPA met Staff #1 (S1) and explained the reason for the visit. S1 contacted Administrator Baltazor Cornejo via phone. The Administrator Baltazor Cornejo arrived at 10:40 a.m., and LPA explained the reason for the visit.

During today’s visit: A physical plant tour of interior facility was completed; with a focus on the bedrooms, bathroom and living room. LPA obtained a copy of staff roster, resident roster and infection control plan. LPA Baptiste took photos of the following items: (broken kitchen doorknobs, the carpet in C1 and C2’s bedrooms, Client couches in the second living room, the broken toilet, C3’s shower, Air vents, and insect traps located in the back yard and in the front of the home. LPA interviewed the administrator and a total of two (2) staff who shall be referred to as S1 and S2. LPA interviewed 1 client who shall be referred to as C1. LPA was unable to interview clients C2 and C3 due to their limited communication.
Report Continued on 9099C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20231117131132
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/21/2023
NARRATIVE
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The investigation reveals the following: Regarding “Facility is unsanitary”. It is alleged that the carpets and couches are dirty. The Program Manager denied the allegation. 2 out of 2 staff confirmed the allegation. During the tour LPA Baptiste observed the carpet, vents, backyard furniture and couches needed cleaning. LPA also observe feces in C3’s bathroom shower. Prior to leaving LPA observed the administrator cleaned out the vents and bathroom.

The investigation reveals the following: Regarding “Facility is malodorous”. It is alleged that the facility has a sewer odor. The Administrator denied the allegations, stating they have not smelled any odors. 2 out of 2 staff confirmed the allegation. During the tour LPA smelled bleach through out the facility except for C3’s bathroom which can be related to the feces. Prior to leaving LPA observed the facility cleaned the feces in C3's bathroom.

The investigation reveals the following: Regarding “Facility has an infestation of insects”. It is alleged that the facility has an infestation of insects (mosquitos, crickets, and spiders). The Administrator confirmed the facility has crickets and mosquitoes. 2 out of 2 staff confirmed the mosquitos and crickets during the night. During the visit LPA did not observe insects but observed a trap in the backyard.

The investigation reveals the following: Regarding “Facility is in disrepair”. It is alleged that the facility has plumbing issues. The Administrator confirmed there has been plumbing issues. 2 out of 2 staff confirmed there is plumbing issues with the bathroom. During the tour LPA observed when the bathroom toilet is flushed the water is overflowed from the tank. LPA also observed the kitchen cabinet doorknob was broken. Light also checked all the lights and observed a broken light in the first living room. Prior to leaving LPA observed the toilet is not overflowing with water and has been repair.

Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore, the above allegations is found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D.



Exit Interview Conducted with administrator/ Appeal Rights Provided / A Copy of the Report Issued.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20231117131132
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/21/2023
Section Cited
CCR
80087(a)
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Buildings and Grounds
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 was not met as evidenced by:
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The Administrator will ensure the facility is clean, sanitary and in good repairs at all times. Staff in service will be conducted and procedures established to ensure proper cleaning of the facility. Staff sign off during in-service, updated procedures and photos of the repairs is due by POC due date.
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Based on observation, and interviews conducted it was revealed that the carpets, couches, kitchen doorknobs, vents, toilet, C3’s shower was either in disrepair or needed cleaning. LPA also observe feces in C3's bathroom shower, which poses a potential health, safety, or personal rights risk to persons in care.
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The bathroom toilet was repaired prior to leaving the facility, C3's bathroom and the vents was also clean prior to LPA leaving the facility.
Type B
12/21/2023
Section Cited
CCR
80087(1)
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Buildings and Grounds
(1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidence by
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The Administrator will ensure the facility is free from insects. Proof of the facility being insect free is due to LPA by POC due date.
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Based on observation, and interviews conducted the administrator and 2 out of 2 staff confirmed the facility has mosquitos and crickets. LPA also observed an insect trap, which poses a potential health, safety, or personal rights risk to persons in care.
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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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3