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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602220
Report Date: 04/14/2022
Date Signed: 04/20/2022 03:05:40 PM

Document Has Been Signed on 04/20/2022 03:05 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 DR #100
MONTERY PARK, CA 91754
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:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Sheleania HamptonTIME COMPLETED:
03:00 PM
NARRATIVE
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On 4/14/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool.

Upon arriving at the facility, LPA met with Administrator Sheleania Hampton and explained the purpose of this visit. LPA was granted access and allowed to enter the facility to conduct an inspection by the Administrator. The facility is licensed to serve three (3) ambulatory, of which one may be non-ambulatory, clients ages 18-59. The facility’s annual fees are current during today’s visit. Clients are referred by the Harbor Regional Center.

LPA toured the single-story facility with Administrator Hampton. The facility consists of three (3) client bedrooms, kitchen, dining area, living room, two (2) bathrooms, washer/dryer located in garage, office area, and backyard patio. Centrally stored medications are locked in a cabinet in the hallway.

There is at least a one week supply of nonperishable and two day supply of perishable foods. The facility is maintained at a comfortable temperature. Hot water temperature measures at 112.0 degrees Fahrenheit. There are working lights in each room to ensure safety and comfort for all clients in the facility.

Report Continued in LIC 809C

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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Document Has Been Signed on 04/20/2022 03:05 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 04/14/2022 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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: AMBITIONS - BRIGHTON AVENUE
FACILITY NUMBER: 198602220

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA did not observe a smoke alarm in bedroom #2. LPA also observed all other smoke alarms are not operable. Administrator admitted a new interconnected smoke alarm system was installed improperly and did not notice it was not operable. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2022
Plan of Correction
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Administrator agreed to repair the smoke alerm system and install a smoke alarm in bedroom #2 by the POC due date. Administrator will send a POC to lourdes.montoya@dss.ca.gov.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Angela J Kendrick
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/20/2022 03:05 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 04/14/2022 at 02:03 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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: AMBITIONS - BRIGHTON AVENUE
FACILITY NUMBER: 198602220

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
(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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed and took a photo of a shovel found in the backyard near a small tree. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2022
Plan of Correction
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Administrator acknowledged the shovel poses an immediate danger to clients in care. Administrator agreed to provide training to staff to ensure dangerous items are locked and inaccessible to clients in care. Administrator moved the shovel into a locked storage inaccessible to cients. This deficiency has been corrected at the time of visit. POC will be emailed to lourdes.montoya@dss.ca.gov by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Angela J Kendrick
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022


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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 DR #100
MONTERY PARK, CA 91754
FACILITY NAME: AMBITIONS - BRIGHTON AVENUE
FACILITY NUMBER: 198602220
VISIT DATE: 04/14/2022
NARRATIVE
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All outdoor and indoor passageways were free of obstruction. The clients have clean linen which includes blankets/bedspreads, top and bottom sheets, pillow cases, and mattress pads. First aid kit had the required items. The facility has a written emergency disaster plan located in the office area. This facility has one operable carbon monoxide detector in the dining area.LPA observed two (2) fire extinguishers last serviced on 1/21/2022. One fire extinguisher is located in the kitchen and another one in the garage. Facility last fire drill was on 4/13/2022.

During the visit, LPA observed the following to be in compliance: the facility's infection control practices; screening protocols for visitors, staff, and client, sanitizing stations in common areas and restrooms; every staff was wearing a face covering; facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has a Mitigation Plan Report approved by CCLD.



Deficiencies were cited.

Exit interview conducted and a copy of this report and appeal rights were provided to Administrator Sheleania Hampton.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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