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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602219
Report Date: 12/07/2022
Date Signed: 12/07/2022 04:27:08 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
11/28/2022 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221128135757
FACILITY NAME:AMBITIONS - 183RD STREETFACILITY NUMBER:
198602219
ADMINISTRATOR:LESLYN VENEGASFACILITY TYPE:
735
ADDRESS:11417 183RD STTELEPHONE:
(562) 219-5799
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY:3CENSUS: 3DATE:
12/07/2022
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Kara Gulling - AdministratorTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Staff dispensed incorrect medication to resident without physician's approval
Staff did not ensure client attended physicians medical appointment
Staff did not seek medical attention in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Kara Gulling (Administrator) and explained the reason for the visit.

The investigation consisted of the following: LPA obtained copies of the client and staff rosters, and interviewed Administrator, Staff 1 (S1), Regional Center Service Coordinator, Facility's Nurse Consultant, Harbor Community Care Clinic Representative and Client 1 - Client 3 (C1 - C3). Copies of C1's admission agreement, Individual Program Plan (IPP), medication records and 11/24/22 urgent care documents were obtained.

The investigation revealed the following: regarding the allegation "staff dispensed incorrect medication to resident without physician's approval”, it is alleged that the administrator was giving C1 left over Ibuprofen that was prescribed 3 months ago. (CONTINUED TO LIC 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
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-20221128135757
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: 12/07/2022
NARRATIVE
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Interview with the administrator revealed that the ibuprofen was administer because it is a PRN medication that was prescribed to C1 in Septembers 2022 and was also given the approval to administer by the facility's nurse consultant. Interview with the facility's nurse consultant revealed that the administrator was told that the ibuprofen can be administer only if it is prescribed to C1 and if it is a PRN medication. Review of C1's medication records did not list the ibuprofen as a PRN medication. Furthermore, the label on the ibuprofen does not state that it is a PRN medication and instead it states to "take 2-3 tablets by mouth every 6 hours as needed for pain for 2-3 days". The ibuprofen was filled on 09/06/22 and it should have been discontinued 2-3 days from the filled date. Clients were not able to answer questions due to their intellectual capabilities.

Regarding the allegation "staff did not ensure client attended physicians medical appointment”, it is alleged C1 missed a physician's telephone appointment on 11/23/22 at 9:15am. Interview with the administrator revealed that on 11/22/22 she scheduled the telephone appointment and due to unforeseen circumstances she was not able to be at the facility from 11/23/22 to 11/28/22. However, S1 was at the facility on 11/23/22 to do the telephone appointment with C1. Interview with S1 revealed that the clinic did call and it was from a nurse to conduct a check in and ask for C1's symptoms. S1 was told that the doctor will be calling soon, but according to S1 that call was not received. Interview with the Harbor Community Care Clinic Representative revealed that the first call is a check in call and it is made by the medical assistant. The check in call was answered by the patient, but the 3 calls made after by the doctor were not answered and therefore they considered this appointment a no show. The doctor called the same number that the medical assistant called for the check in. Additionally, C1's family member received a text message that C1 missed this doctor's appointment. Clients were not able to answer questions due to their intellectual capabilities.

Regarding the allegation "staff did not seek medical attention in a timely manner”, it is alleged that on 11/16/2022, C1 began to be sick with a cold and flu like symptoms and was not taken to see a doctor while he was sick. Interview with the administrator revealed that there was no in-person appointments available thus a virtual appointment was done on 11/18/22 through Teladoc and they recommended for C1 to stay home due to C1's symptoms and if C1 did not get better then to follow up with primary doctor. C1 did not get better and thus the 11/23/22 telephone appointment was scheduled. Facility did not take C1 to urgent care. C1's family member received a text message that C1 missed the telephone doctor appointment on 11/23/22 which led to the family member taking C1 to an urgent care on 11/24/22 and C1 was diagnosed with acute bronchitis. Review of urgent care documents dated 11/24/22 confirmed that C1 was diagnosed with acute bronchitis. Clients were not able to answer questions due to their intellectual capabilities. (CONT. TO LIC 9099C)
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20221128135757
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: 12/07/2022
NARRATIVE
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Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are 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.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20221128135757
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: 12/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/08/2022
Section Cited
CCR
80075(b)(6)(A-D)
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80075 Health Related Services
(b) Clients shall be assisted as needed....
(6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication...facility staff designated by the licensee, shall be permitted to assist the client with self-administration...
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Facility is to ensure that Title 22 Section 80075 regulations are met at all times. Additionally, an in-service training is to be conducted regarding Title 22 Section 80075 and a training log with staff signature submitted to CCLD by 12/12/2022.
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This requirement is not met by:
Based on records review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Facility administered ibuprofen to C1 that should have been discontinued 2-3 days from the filled date 09/06/22.
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Type A
12/08/2022
Section Cited
CCR
85075(b)
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85075 Health-Related Services
(b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs.
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Facility is to ensure that Title 22 Section 85075 regulations are met at all times. Additionally, an in-service training is to be conducted regarding Title 22 Section 85075 and a training log with staff signature submitted to CCLD by 12/12/2022.
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This requirement is not met by:
Based on interviews and records review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Facility did not ensure the client attended physicians medical appointment on 11/23/22.
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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.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 28-AS-20221128135757
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: 12/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/08/2022
Section Cited
CCR
80075(a)
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80075 Health Related Services
(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
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Facility is to ensure that Title 22 Section 80075 regulations are met at all times. Additionally, an in-service training is to be conducted regarding Title 22 Section 80075 and a training log with staff signature submitted to CCLD by 12/12/2022.
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This requirement is not met by:
Based on interviews and records review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Facility did not take the client to urgent care to get in-person medical assistance.
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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.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5