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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602219
Report Date: 08/01/2023
Date Signed: 08/01/2023 03:55:11 PM

Document Has Been Signed on 08/01/2023 03:55 PM - 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 STREETFACILITY NUMBER:
198602219
ADMINISTRATOR:LESLYN VENEGASFACILITY TYPE:
735
ADDRESS:11417 183RD STTELEPHONE:
(562) 219-5799
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 3CENSUS: 3DATE:
08/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Program Manager Christopher YoungTIME COMPLETED:
04:06 PM
NARRATIVE
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On 8/01/23 at 9:19 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to the facility in conjunction with a Case Management visit. Upon arrival LPA met with staff S1 who called the Administrator Tranae Gatlin and Program Manager Christopher Young to explained the purpose of the visit. Program Manager Christopher Young arrived at 11:00 and joined the visit.

During today’s visit LPA toured the facility with staff S2. LPA obtained resident roster, staff roster, pictures of property damage, pictures of R1’s injuries and a photo of the thermostat. LPA also interviewed: Program Manager Christopher Young and a total of two (2) staff who shall be referred to as S1, and S2. LPA attempted to interview a total of 3 residents who shall be referred to as: R1 through R3. Due to the residents limited communication LPA was not able to use resident’s interviews. LPA was unable to conduct file review due to the administrator being unavailable and have the keys that access the files.

During the investigation LPA interview S1 and S2 who both stated they work with a registry. They stated they have been working on an off at the facility for a year. LPA reviewed association list and observed both staff was not associated to the facility. LPA interviewed Program Manager Christopher Young via telephone and confirmed both staff are not associated, and the facility may have an exception for registry staff. Program Manager arrived at 11:00 and was unable to provide proof of exemption for registry staff.

Exit interview was conducted with program Manager Christopher Young, a copy of this report, 809D and appeals rights was provided.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 08/01/2023 03:55 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 08/01/2023 at 02:00 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: 08/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/10/2023
Section Cited
CCR
80066(e)

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80066 Personnel Records (e) All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
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Licensee will ensure that personnel records are always available for review at time of CCL visit, or made available within the time frame of the visit.
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Based on LPA interview and observation, the files was locked at the facility but facility staff did not have the key to open the files, which poses a potential Health and Safety risk to clients 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:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/01/2023 03:55 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 08/01/2023 at 02:11 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: 08/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2023
Section Cited
CCR
80019(e)(1)

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 80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:(1)Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
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The Licencee will ensure all registry staff is associated and have a background clearence prior to starting work at th facility by POC due date.
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Based on record review, the licensee did not comply with the section cited above in that staff (S1) and (S2) are not associated to the facility or have a facility background clearence by DOJ; which poses an immediate 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:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023


LIC809 (FAS) - (06/04)
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