198602219-12-19-2023-28-AS-ACAN-CYG2UP-20231212164239

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602219
Report Date: 12/12/2023
Date Signed: 12/19/2023 08:37:34 AM

Document Has Been Signed on 12/19/2023 08:37 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

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:	12/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:36 PM
MET WITH:	Administrator Baltazar Cornejo		TIME COMPLETED:	04:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced annual visit using the CARE inspection Tool. LPA met with Staff / Administrator Baltazar Cornejo and explained the reason for the visit.

On today's visit: physical plant was toured and conducted alongside with Administrator, food supply was inspected.

The following was observed, reviewed and inspected:

LPA toured the home and inspected (3) client bedrooms, (3) bathrooms, living room, kitchen, dining room, office area, and detached garage. During time of visit only (1) client was present, (2) clients were at day program. All staff present at the time of visit were cleared and associated.

Passageways and exits were observed to have deficiencies. Client's bedroom #1 and bedroom #2, lead to the side yard / side runner, not clear of debris and obstructions, side yard was observed to have empty bins and containers, wooden boards and planks and a broken window screen.

The water temperature was tested and is within the required Title 22 regulation of: 105F - 120F degrees.
Client bedrooms #1 and #2 have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Client #3 has a bed mattress only due to property destruction behavior noted on annual plan, dated 10/23/23.

LPA observed (3) bathrooms. Bathroom #1-toilet lid missing and exposes client to a safety hazard. Bathroom #2 noted to have missing shower head. Bathroom #3 is under repair, deficiency noted.

Smoke detectors were observed throughout the facility and were tested and operable during the visit. There is a carbon monoxide detector that is hardwired with the smoke alarm system. Fire extinguisher's in the home were fully charged. (CONTINUATION 809-C...)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AMBITIONS - 183RD STREET	FACILITY NUMBER: 198602219
	VISIT DATE: 12/12/2023

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Kitchen appliances are clean and appliances were operating at the time of the visit. Sharps are locked in a kitchen drawer and are inaccessible to clients. Cleaning supplies and disinfectants are locked under the sink and in separate cabinets and are inaccessible to the clients. Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed. Refrigerator was observed to have handle on freezer door broken, plastic side door tray cracked, and plastic rubber lining torn, deficiency noted.

First Aid Kit was fully stocked.

Laundry area is placed in the kitchen area. Wash machine was observed broken, broken plastic door ledger, latch broken on left side, unattached to door, deficiency noted.

The front and backyard was observed, no pools/ large bodies of water was observed. There is a shaded seating area for the clients located in the backyard. Backyard was observed to have unlocked storage/tool items and (2) poison bottles of bug killer repellent was found in the backyard accessible to clients in care. Pile of maintenance tools, old equipment, and wooden boards and wooden planks and panels located on side yard, and backyard. Deficiencies noted.

Administration Certification Expired, Administrator submitted LIC9214 for renewal and will submit certification upon receiving documentation.

Due to insufficient time, visit will continue at a further time. A copy of this report will be emailed to Administrator.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies were cited on LIC809-D. Exit interview held and a copy of the report will be provided to Administrator via email.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/19/2023 08:37 AM - It Cannot Be Edited

Created By: Ashley Calderon On 12/12/2023 at 03:47 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AMBITIONS - 183RD STREET	FACILITY NUMBER: 198602219
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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
1 2 3 4	Based on observation LPA and Administrator observed (2) poison bottles of bug killer repellent, found in the backyard accessible to clients in care and interview, the licensee/ facility did not comply with the section cited above in [3] out of [3] clients in care, are posed to an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/13/2023
	Plan of Correction
1 2 3 4	Administrator immediately locked poison bottles to a locked cabinet making it inaccessible to clients in care. Administrator will conduct in-service training with staff / maintenance staff on Regulation 80087 and how to properly lock disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Fernando Fierros

LICENSING EVALUATOR NAME:

Ashley Calderon

LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 12/19/2023 08:37 AM - It Cannot Be Edited

Created By: Ashley Calderon On 12/12/2023 at 03:47 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AMBITIONS - 183RD STREET	FACILITY NUMBER: 198602219
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation with Administrator and interview with Administrator, the licensee/ facility did not comply with the section cited above in [3] out of [3] clients in care, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2024
	Plan of Correction
1 2 3 4	Administrator will submit: Toilet lid picture with proof of purchase for bathroom #1, bathroom #2 proof of installed shower head, and bathroom #3 needs repair and . picture of work order for backyard cleaning for removal of items such as: old equipment, storage items, wooden pallets, board and panels. Facility will fix or replace washer appliance / referigertor and submit pictures.

Type B

Section Cited

CCR

80087(c)

Building and Grounds

(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation alongside with Administrator Client #1 and Client #2 side yard / runner was observed to have empty containers, wooden boards and broken window screen, the licensee did not comply with the section cited above in [2] out of [3] clients in care, which poses to a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	Administrator will submit a picture of items removed from the side runner and a clear side yard/ runner by POC due date.

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:

Fernando Fierros

LICENSING EVALUATOR NAME:

Ashley Calderon

LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC809 (FAS) - (06/04)

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