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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602199
Report Date: 09/19/2024
Date Signed: 09/19/2024 11:26:07 AM

Document Has Been Signed on 09/19/2024 11:26 AM - 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:AMBITIONS - CARSON DAY PROGRAMFACILITY NUMBER:
198602199
ADMINISTRATOR/
DIRECTOR:		JUAN AMBROSEFACILITY TYPE:
775
ADDRESS:329 W TORRANCE BLVDTELEPHONE:
(310) 715-1796
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 60CENSUS: 20DATE:
09/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:06 AM
MET WITH:Amado Achiva - Executive Director TIME VISIT/
INSPECTION COMPLETED:
11:37 AM
NARRATIVE
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On 09/19/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced Case Management visit at this facility. LPA was greeted by Executive Director Amado Achiva and explained the purpose of the visit to conduct a health and safety check. LPA explained the inspection visit is in association with an incident on 09/10/24.

On 09/10/24, Cathy Nguyen , Site Manager reported an incident concerning client #1 (C1) and staff #1 (S1) involving (C1) who gained access to a toxic chemical. Information reported indicated (S1) was cleaning and spraying down the gym area with Lysol Disinfectant when (C1) got a hold of the toxic chemical and sprayed in (C1’s) mouth.

The Department interviewed Executive Director (ED#1) regarding the incident involving (C1) and (S1). (ED#1) stated the (S1) had left out the toxic chemical that (C1) gained access to the hazardous chemical.

During today's inspection visit, LPA Dabuet audited service records for clients #1 (C1) and staff #1 (S1). As a result of a review of (C1’s) Preplacement Appraisal LIC 603 (dated: 03/21/24) and Individual Person Center Plan (dated: 10/27/23) it revealed (C1) requires adult supervision while out in the community and requires special observation due to short attention span/wandering behavior.

Based on observations, interviews, and record reviews, a preponderance of evidence standard has been met. (S1) failed to carry out the responsibilities and duties of a Direct Support Provider who failed to store toxic chemicals and allowed access for clients in care. California Code of Regulations, Title 22, Division 6, and Chapter 3 are being cited on the attached LIC 809-D.

An exit interview was conducted with Cathy Nguyen and a hard copy of the report along with appeal rights.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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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Document Has Been Signed on 09/19/2024 11:26 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 09/19/2024 at 10:39 AM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AMBITIONS - CARSON DAY PROGRAM
FACILITY NUMBER: 198602199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2024
Section Cited
CCR
82087(a)(3)(a)

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82087 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.
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Licensee/Program Director agreed to comply with and review Title 22 Regulation, 82087 and will ensure that all toxic chemicals harmful to clients in care are stored and inaccessbile to clients. POC must be sent to LPA Dabuet via email: ernand.dabuet@dss.ca.gov
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This requirement is not met as evidenced by:
Based on interviews and record review, (S1) failed to carry out the duties and responsiblites and left toxic chemical unattended and accessible to (C1) who has wandering behavior. This violation poses an immediate health, safety or personal rights risk to persons in care.
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*Corrected During Visit *
Type B
10/03/2024
Section Cited
CCR82065(a)(e)

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82065 Personnel Requirements
(a) Program personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times...(e) The licensee shall provide for direct supervision of clients during participation in or presence at potentially dangerous activities or areas in the
day program.
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Licensee/Program Director agreed to comply with and review Title 22 Regulation, 82065 and will ensure all staff complete a training on Member Support and Safety Procedures. A sign-in sheet with all staff who completed the training is due by POC date to LPA Dabuet via email: ernand.dabuet@dss.ca.gov
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This requirement is not met as evidenced by:
Based on interviews and record review, The day program staff failed at supervision for (C1) who had a behvior of wandering and injest a toxic chemical. This violation 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.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


LIC809 (FAS) - (06/04)
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