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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602219
Report Date: 09/29/2025
Date Signed: 09/29/2025 01:51:03 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
08/20/2025 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250820144520
FACILITY NAME:AMBITIONS - 183RD STREETFACILITY NUMBER:
198602219
ADMINISTRATOR:ASHILEE JACKSONFACILITY TYPE:
735
ADDRESS:11417 183RD STTELEPHONE:
(562) 219-5799
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY:3CENSUS: 2DATE:
09/29/2025
UNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH: Program Manager Sheleania HamptonTIME COMPLETED:
01:58 PM
ALLEGATION(S):
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Staff did not properly report incident to licensing agency
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Alberto Lopez and Sakinah Madyun made subsequent visit to investigate the above allegation. LPA met with staff Ryan Currey and Program Manager Sheleania Hampton assisted with the visit.

On 08/22/2025 - Licensing Program Analyst (LPA) Alberto Lopez conducted an initial 10-day complaint investigation regarding the above allegations. LPA discussed the purpose of the visit with DSP Vivian Yates and explained the purpose of the visit.

The investigation consisted of: A physical plant tour of the interior of the facility. Client (C1's) entire file was requested to be sent to LPA. LIC 500, Personnel Record, and resident rosters were obtained during visit.
Further investigation is needed.

(continued on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025
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 5
Control Number 28-AS-20250820144520
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AMBITIONS - 183RD STREET
FACILITY NUMBER: 198602219
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/03/2025
Section Cited
CCR
80061(b)
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80061(b) Reporting Requirements. Upon the occurrence, of specified events, reports shall be made to the licensing agency within the agency's next working day. In addition, written reports shall be submitted to the licensing agency within seven days following the occurrence of such events.
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Licensee/Administrator shall review Section 80061 and ensure to report occurrence, of special events to the licensing agency within the stipulated timelines and send written report acknowledging that section 80061 has been reviewed an understood. In addition all staff will be trained on reporting requirements.
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During complaint investigation visit it was noted that although a Special Incident Report was generated for the incident occurring on 08/10/2025, it was sent 16 days later on 08//26/2025. It was not provided to CCLD in a timely manner as stipulated in Title 22 which poses/posed a potential health and 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.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20250820144520
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: AMBITIONS - 183RD STREET
FACILITY NUMBER: 198602219
VISIT DATE: 09/29/2025
NARRATIVE
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(continued from 9099)

Previous to visit LPA obtained C1 pertinent file records, photos, and two incident reports.

On 09/29/2025, LPAs interviewed five (5) staff #1 - #5 and had interviewed C#2 on previous visit. C#1 moved and is unable to answer questions due to cognitive impairment. C#3 could not answer questions due to cognitive impairment.

Then investigation revealed: Allegation: Facility did not properly report incident to licensing agency.

There was an incident that occurred on 08/10/2025 at around 2:40 PM at home where C1 ran out the door, tripped and fell and hit face. Facility sent incident report to the department on 08/26/2025 which is 16 days after the incident. S4 stated S4 was told to send report and agreed that it was sent past the 7 days that is required by the department. There is sufficient evidence to substantiate this allegation.

Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 1 & 6 are being cited on the attached LIC 9099D. Exit interview held and a copy of the report and appeal rights was provided.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
08/20/2025 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250820144520

FACILITY NAME:AMBITIONS - 183RD STREETFACILITY NUMBER:
198602219
ADMINISTRATOR:ASHILEE JACKSONFACILITY TYPE:
735
ADDRESS:11417 183RD STTELEPHONE:
(562) 219-5799
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY:3CENSUS: 2DATE:
09/29/2025
UNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Program Manager Sheleania HamptonTIME COMPLETED:
01:58 PM
ALLEGATION(S):
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Resident sustained multiple injuries due to lack of care from staff
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Alberto Lopez and Sakinah Mudyan made subsequent visits to investigate the above allegations. LPA met with staff Ryan Currey and Program Manager Sheleania Hampton assisted with the visit.

On 08/22/2025 - Licensing Program Analyst (LPA) Alberto Lopez conducted an initial 10-day complaint investigation regarding the above allegations. LPA discussed the purpose of the visit with DSP Vivian Yates and explained the purpose of the visit.

The investigation consisted of: A physical plant tour of the interior of the facility was conducted. Client (C1's) entire file was requested to be sent to LPA. LIC 500 Personnel Record, and resident rosters were obtained.
Further investigation is needed.

(continued on 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20250820144520
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: AMBITIONS - 183RD STREET
FACILITY NUMBER: 198602219
VISIT DATE: 09/29/2025
NARRATIVE
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(continued from 9099A)

Allegation: Resident sustained multiple injuries due to lack of care from staff. It is alleged that C1 suffered injuries due to lack of care and supervision.

LPA interviewed five (5) staff and all five (5) denied the allegation. LPA interviewed one (1) client (C2) and C2 stated C2 is happy at facility and gets good care. On 08/10/2025 C1 was returning from outing and refused to get out of the van. S2 who was driving the van, attempted to talk C1 into getting off the van and going inside the home. After a while S2 stated C1 went inside the home. At that time, S2 stated S2 went to kitchen to write notes and heard S5 yelled that C1 had run out the door, S2 stated he ran to attempt to catch C1 and saw C1 trip over the mat outside the front door and hit his face. S2 stated C1 did not attempt to use C1 hands to break C1 fall. S2 then redirected C1 into the home and sat C1 down on the couch and did not notice any injuries on C1 face at that time. S5 who was present during the incident stated S5 did not notice any injuries on C1 face. S1 stated S1 was not at facility during the incident and cannot provide details. On 08/19/2025, client eloped from facility at around 6:00am and staff contacted Lakewood Sheriff Department right away and C1 was found walking on the 91 freeway and brought back to facility by 6:52am and did not have any reported injuries. There was one (1) staff supervising three (3) clients which is within the ratio mandated. Staff decided to remain with the other two (2) clients and contacted Administrator and Sheriff. There is insufficient evidence to support this allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted. A copy of this report was provided.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5