<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602219
Report Date: 01/02/2025
Date Signed: 01/02/2025 12:43:26 PM

Document Has Been Signed on 01/02/2025 12:43 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:AMBITIONS - 183RD STREETFACILITY NUMBER:
198602219
ADMINISTRATOR/
DIRECTOR:		ASHILEE JACKSONFACILITY TYPE:
735
ADDRESS:11417 183RD STTELEPHONE:
(562) 219-5799
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 3CENSUS: 2DATE:
01/02/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Ann Hyde, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Case Management Visit to follow up on a Death Report faxed to the Department on 12/26/24. LPA was allowed entry by S2 and explained the purpose of the visit. Administrator, Ann Hyde arrived shortly after and LPA explained the purpose for the visit. Administrator, Ann Hyde assisted LPA with the visit.

It was reported to Community Care Licensing (CCL) received on 12/26/2024 from Ambitions - 183rd Street that on 12/21/2024 at 3:50am, C1 was having difficulty breathing and balancing, home staff assisted C1. Home staff contacted 9-1-1. Paramedics transported C1 to the hospital. C1 went into cardiac arrest and was put on life support. C1 passed away on 12/24/24 at 1:50am.

During today's visit LPA interviewed the Administrator and S1. LPA obtained copies of C1's Face Sheet, Individualized Program Plan (IPP), Physician's Report, Medication Administration Record (MAR) from September 2024 to January 2025 and the Special Incident Report (SIR) prior to the incident.

LPA also toured C1's bedroom. No concerns, obstructions, or anything out of the ordinary was witnessed during the visit. LPA will also request facility to obtain and provide Licensing with C1's Death Certificate upon receipt if available.

It is determined that the Case Management visit will require further investigation. No deficiencies observed during today's visit. Exit interview held and a copy of the report was provided to the Administrator, Ann Hyde.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2025
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 1