198602219-8-31-2021-28-AS-RORN-C6EUDJ-20210831152934

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602219
Report Date: 08/31/2021
Date Signed: 08/31/2021 03:19:58 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
04/05/2021 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-NP-20210405100624

FACILITY NAME:	AMBITIONS - 183RD STREET		FACILITY NUMBER:	198602219
ADMINISTRATOR:	LESLYN VENEGAS		FACILITY TYPE:	735
ADDRESS:	11417 183RD ST		TELEPHONE:	(562) 219-5799
CITY:	ARTESIA	STATE: CA	ZIP CODE:	90701
CAPACITY:	3	CENSUS: 3	DATE:	08/31/2021
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Monica Edualino - Program Manager		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff handle client roughly

INVESTIGATION FINDINGS:

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This is a corrected version of report dated 4/12/21. The reason for the correction is to add information regarding video reviewed.

On 4/12/21 Licensing Program Analyst (LPA) Mary Flores initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Monica Edualino, the facility program manager. On 8/31/21 LPA Flores requested a copy of video mentioned on SIR submitted to the department on 4/1/21.

Investigation consisted of the following: LPA Flores conducted a video call and interviewed program manager, 3 clients, 2 staff, and conducted a tour of the facility which consisted of observation of kitchen, common areas, 3 bathrooms, and 3 clients' rooms. LPA observed all sharps, medications, and chemicals were kept under lock. No health and safety concerns at this moment. The LPA also requested copies of staff roster, client roster, medication sheets for current month, Individualized Progress Plan (IPP), face sheets, (Continued on 9099C)

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-NP-20210405100624

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 - 183RD STREET	FACILITY NUMBER: 198602219
	VISIT DATE: 08/31/2021

NARRATIVE

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admissions agreements for all clients, termination letters for 3 staff, copy of unusual incident report and trainings provided to staff last three months.

The investigation revealed the following: Regarding allegation; Staff handled client roughly. It is alleged a staff pull client #1(C1) from couch and fell on the ground. LPA Flores attempted to interview client #1(C1), client #2(C2), and client #3(C3) but was unable as C1,C2,C3 are non-verbal and/or due to cognitive skills. During interviews with staff, 2 out of 4 staff stated that 2 staff have been terminated due to allegations of abuse towards the clients and 2 out of 4 staff were new and had not been aware of any abuse. On 4/1/21 facility submitted unusual incident report to the department via fax in which the following was stated, "staff was observed being physically and verbally aggressive with C1 by forcefully removing C1 off the couch to the ground". During the investigation, program manager stated 2 staff have been terminated after investigation of allegations regarding physical and verbal abuse. Program manager provided a copy of the termination letters, staff #5(S5) and staff #6(S6) were placed on disciplinary leave on 3/31/21 due to abuse allegations and terminated as of 4/6/21. Termination letter for previous administrator was also provided, who was terminated on March 19, 2021. LPA contacted South Central Regional Center, and Harbor Regional Center to request any reports or findings for their investigation. LPA left a message at quality assurance specialist department. On 8/31/21 LPA Flores obtained and reviewed a copy of video mentioned on incident report 4/1/21 "On 3/31/21 a video was brought to management attention..." Video shows C1 being pulled of the couch and falling in the ground and staff's behavior continuing.

Based on LPA's interviews, and records review conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with Program Manager, Monica Edualino. A copy of the report, LIC 9099D, and Appeal Rights was provided to the program manager.

NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-NP-20210405100624

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 - 183RD STREET	FACILITY NUMBER: 198602219
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/31/2021 Section Cited CCR 80072(a)(1)	1 2 3 4 5 6 7	80072 Personal Rights; Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1)To be accorded dignity in his/her personal relationships with staff and other persons. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Facility will ensure all clients are treated and accorded dignity in all their relationships with staff at all times, will sign and certify by submitting an LIC 9098 within 24 hours and will conduct in service training within 7 days and provide a copy of agenda and in service for personal rights training.
	8 9 10 11 12 13 14	Based on interviews and records reviewed 1 out of 3 clients was not accorded dignity in his/her relationships with staff, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
Type A 08/31/2021 Section Cited CCR 80072(a)(3)	1 2 3 4 5 6 7	80072 Personal Rights;... each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment,... mental abuse, or other actions of a punitive nature,... This requirement is not met as evidence by:	1 2 3 4 5 6 7	Facility will ensure all clients are treated and accorded dignity in all their relationships with staff at all times, will sign and certify by submitting an LIC 9098 within 24 hours and will conduct in service training within 7 days and provide a copy of agenda and in service for personal rights training.
	8 9 10 11 12 13 14	Based on interviews and records reviewed 1 out of 3 clients was pulled of the couch and fell hitting his head whcih poses an immediate Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14

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: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

LIC9099 (FAS) - (06/04)

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