198602117-12-29-2023-11-AS-SLEO-CYYVBR-20231229151758

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602117
Report Date: 12/29/2023
Date Signed: 12/29/2023 03:18:09 PM

Document Has Been Signed on 12/29/2023 03:18 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 - DENKER AVENUE		FACILITY NUMBER:	198602117
ADMINISTRATOR:	ARANA, EDGAR		FACILITY TYPE:	735
ADDRESS:	20942 DENKER AVE		TELEPHONE:	(424) 558-3885
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY: 3		CENSUS: 3	DATE:	12/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Doris Bell-Tabbs - Program Manager		TIME COMPLETED:	03:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/29/2023 at around 8:10 AM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the Program Manager Doris Bell-Tabbs. LPA explained the purpose of the visit and was accompanied by a staff member inside and outside the facility during this inspection. This facility is licensed to serve 3 adults ages 18 – 59 years, of which 2 may be non-ambulatory clients. A total of 3 clients are currently residing in this facility, of which 1 is non-ambulatory clients. The facility has a past due balance of $454. The facility is a one-story house located in a residential street. The home consists of 3 client bedrooms, 2 bathrooms, 1 kitchen/dining/living/tv/office area, 1 attached garage, 1 laundry area, and 1 backyard patio area with shaded seating. Outside grounds were toured and no bodies of water were observed. LPA observed green mold on the backyard concrete walkway. The patio furniture is under a shaded area and accessible to clients. There are no security bars or weapons on the premises. LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

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 4

Document Has Been Signed on 12/29/2023 03:18 PM - It Cannot Be Edited

Created By: Socorro Leandro On 12/29/2023 at 02:42 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 - DENKER AVENUE	FACILITY NUMBER: 198602117
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/29/2023

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, the licensee did not comply with the section cited above in having broken window blinds in bedroom #2; having very dusty window blinds in bedroom #1; bathroom #1's bathtub had dry dirt on the bottom; backyard concrete had bright green mold, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Licensee will: fix bedroom #2's window blinds, clean bedroom #1's window blinds, remove dry dark stains from bathroom #1, and remove the bright green mold from the outside concrete. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

Type B

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation], the licensee did not comply with the section cited above in hot water temperatures mesuaring 99.8 degrees F, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Licensee will fix hot water temperature to mesuare 105 to 120 degrees F. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

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:

Ulysses Coronel

LICENSING EVALUATOR NAME:

Socorro Leandro

LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 12/29/2023 03:18 PM - It Cannot Be Edited

Created By: Socorro Leandro On 12/29/2023 at 02:42 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 - DENKER AVENUE	FACILITY NUMBER: 198602117
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1537.1(a)

Regulations

(a) A licensee of a residential facility serving adults that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for client use. 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 in not having a videoconferencing device dedicated for client use, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Licensee will provide clients with a videoconferencing device dedicated for client use. Licensee will email proof of correction to Socorro.Leandro@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:

Ulysses Coronel

LICENSING EVALUATOR NAME:

Socorro Leandro

LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

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 - DENKER AVENUE	FACILITY NUMBER: 198602117
	VISIT DATE: 12/29/2023

NARRATIVE

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LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Mandated documents are in a binder. Last drill was conducted on 9/18/2023. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There is one fire extinguisher in the kitchen area and was last serviced on 1/18/2023. There is a land line telephone on the kitchen counter top. There is no videoconferencing device dedicated for client use.

2 out of 3 client’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. LPA observed bedroom #1's window blinds had dry dirt on it and bedroom # 2's had broken window blinds. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. LPA observed bathroom #1’s having dry dirt stains on the bottom of the bathtub. Adequate lighting and toiletries accessible to clients. LPA tested hot water temperature and it measured between 99.8 degrees Fahrenheit. This facility provides clients with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

5 staff records were reviewed, 5 out of 5 staff records had current First Aid Certificates, Criminal Record Clearances, Job Applications, Tuberculosis Test, Facility Trainings/Drills, and signed Employee Rights.

3 client records were reviewed and, 3 out of 3 client records had Admission Agreements, Consent Forms, Weight Record, Emergency Information, Appraisal & Needs Service Plan, Tuberculosis Test, Centrally Stored Medication Destruction Record, Safeguards for Cash Resources, Personal Rights, and Cash Resource Information.

Deficiencies are being cited based on LPA observation, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D's. A violation regarding: facility shall be clean, safe, sanitary and in good repair at all times; videoconferencing device dedicated for client use; and hot water temperatures.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

LIC809 (FAS) - (06/04)

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