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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602199
Report Date: 07/11/2022
Date Signed: 07/11/2022 08:44:06 PM

Document Has Been Signed on 07/11/2022 08:44 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:AMBITIONS - CARSON DAY PROGRAMFACILITY NUMBER:
198602199
ADMINISTRATOR:JUAN AMBROSEFACILITY TYPE:
775
ADDRESS:329 W TORRANCE BLVDTELEPHONE:
(310) 715-1796
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 60CENSUS: 6DATE:
07/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Amado Achiva - Executive DirectorTIME COMPLETED:
12:45 PM
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On 07/11/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with site manager Amado Achiva and explained the purpose of today’s visit. The day program is licensed to operate for sixty (60) ambulatory of which ten (10) may be non-ambulatory ages 18 and over. The consumers are Harbor Regional Center clients.

The day program is a single-story structure located in a commercial neighborhood. It consists of the following: administrative office, consultation area, conference room, physical activity room, arts and crafts room, controlled multi-sensory stimulation room (SPA), computer lab area, break room/kitchen area, laundry area, music room, salon, and (2) designated restrooms (1) men (1) women restrooms- toilets and sinks are operable. A changing room with a private shower.

LPA and manager toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected and had adequate lighting furnishings. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 106.9 F. A comfortable temperature of 70 degrees was maintained.

LPA observed the day program to be sanitary and appropriately supplied at the time of the visit. Storage rooms for cleaning supplies, and toxins, were stored and not accessible to consumers. The kitchen was inspected and found all appliances in working condition. Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable. The day program has several working landline phones.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMBITIONS - CARSON DAY PROGRAM
FACILITY NUMBER: 198602199
VISIT DATE: 07/11/2022
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INFECTION CONTROL:
During this visit, LPA observed the day program's infection control practices. LPA observed screening protocols for visitors, staff, and consumers, and sanitizing stations in common areas and restrooms. LPA observed staff and consumers were wearing face coverings, and LPA observed the facility had a sufficient supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff COVID-19 and N-95 Fit Tests were maintained in order, accurate, and complete. The day program has an approved Mitigation Plan with CCLD and has submit an Infection Control Plan for 2022.

DEFICIENCY:
During the inspection, LPA observed at 11:24 am (2) sharp/cutting knifes stored inside a dishwasher.

Deficiency cited during this vist. An exit interview was conducted with Amado Archiva and a copy of this report was provided and appeal rights.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
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Document Has Been Signed on 07/11/2022 08:44 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 07/11/2022 at 12:14 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 - CARSON DAY PROGRAM
FACILITY NUMBER: 198602199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 (2) sharp buther/cutting knifes were stored in a dishwaser accessible to consumers in care. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2022
Plan of Correction
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The Licensee will adhere to Title 22 regulation 82087 and ensure that all hazadous items including sharp objects are stored in locked sotrages/cabinets/drawers at all times. A correction must be submitted by POC date 07/12/22.

*This violation was corrected during the visit.*
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022


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