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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602220
Report Date: 09/26/2024
Date Signed: 10/20/2024 10:26:33 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/25/2022 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20220825114008
FACILITY NAME:AMBITIONS - BRIGHTON AVENUEFACILITY NUMBER:
198602220
ADMINISTRATOR:LIDIA TEJEDAPOSASFACILITY TYPE:
735
ADDRESS:21325 BRIGHTON AVETELEPHONE:
(310) 817-6100
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY:3CENSUS: 3DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Tomoya Henderson, Direct Support ProfessionalTIME COMPLETED:
12:09 PM
ALLEGATION(S):
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Staff caused injuries to resident.
INVESTIGATION FINDINGS:
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On 9/26/24, Licensing Program Analyst, (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by staff, Tomoya Henderson and explained the purpose of the visit is to deliver findings for the allegations mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:
On 8/26/22, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced visit to this facility. LPA was met by Kelli Pinkney, Administrator, Program Manager “China” Hampton and joined by Harbor Regional Center Juan Bermudez. LPA requested records for client (C1-C3) and received the staff roster and the resident roster. LPA Senaha interviewed staff (S1-S4) and client (C2). LPA Senaha received the following documents for C1: Medical records from Harbor – UCLA Medical Center, Special Incident Report’s, emailed communications from regional representatives, 1st quarter ISP for report period 12/1/2021 to 2/28/2022. On 9/23/24 LPA Shirley interviewed C1 and requested CPI records for staff. An attempt was made to interview C2, but they were not available.

Con'd on 9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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 4
Control Number 11-AS-20220825114008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: AMBITIONS - BRIGHTON AVENUE
FACILITY NUMBER: 198602220
VISIT DATE: 09/26/2024
NARRATIVE
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The investigation revealed the following:

Allegation: Staff caused injuries to resident

It is alleged that resident was found to have multiple bruises all over their body. LPA Felisa Shirley reviewed facility records. 1st quarter ISP for C1 generated for report period 12/1/2021 to 2/28/2022 shows C1 has a history of behavior issues, physical aggression and property destruction. Incident report dated 8/9/22, 12:10am shows that C1 began a verbal outburst in their bedroom. Client was told he was not being safe and asked to sit in living room. While in living room, C1’s behaviors escalated and he became physically aggressive towards staff. Staff 1 and Staff 2 (S1 and S2) implemented a two person CPI technique to deescalate the situation. SIR states that C1 obtained minor injuries which were treated by first aid. SIR dated 8/16/22 shows that client became very aggressive with staff and after several attempts at redirection and destruction of facility property, LAPD was called and C1 was transported to Harbor UCLA Hospital Psychiatric unit. According to Harbor-UCLA Medical Center records, C1 was admitted on 8/16/2022 on a psychiatric hold as a possible danger to others. During C1’s admission, hospital performed a physical exam and found abrasions on C1’s left wrist as well as a large bruise covering posterior surface of forearm.



On 8/26/2022 LPA Don Senaha interviewed facility staff. During interviews, S1 and S2 stated C1 became physically aggressive with them on 8/9/2022 and they implemented CPI techniques to deescalate the situation.

Con'd on 9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20220825114008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: AMBITIONS - BRIGHTON AVENUE
FACILITY NUMBER: 198602220
VISIT DATE: 09/26/2024
NARRATIVE
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LPA Shirley completed a further review of facility records and found a follow-up Incident Report dated 8/16/22. The incident report indicated that staff did not follow appropriate CPI techniques or protocol as the CPI hold was properly implemented but was not carried out in appropriate setting. CPI hold was implemented on the couch, and it should have been implemented in a chair.

Based on interviews that were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D.

A copy of this report is being signed by staff, Eric Garnett to be given to the Administrator, Kelli Pinkney.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20220825114008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AMBITIONS - BRIGHTON AVENUE
FACILITY NUMBER: 198602220
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2024
Section Cited
CCR
85165(a)
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85165 Emergency Intervention Staff Training


(a) The licensee shall ensure staff who use, participate in, approve. or provide visual checks of manual restraint or seclusion only use techniques specified in the Emergency Intervention Plan and which are not prohibited in Section 85102.

This requirement is not met as evidenced by:
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All staff and Administrator shall be trained in Crisis Prevention and Intervention, (CPI) and submit proof of current CPI cards, Internal trainings and emergency interventions to LPA, Felisa Shirley via Fax 424-544-1016 or email, felisa.shirley@dss.ca.gov by POC correction date of 11/1/24.
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Based on interview, and record review, an improper use of Crisis Prevention and Intervention, (CPI) techniques resulted in C1 sustaining injuries. Hold was administered on C1 by S1 and S2, which poses a potential health and safety risk to all residents 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.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4