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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602220
Report Date: 03/13/2024
Date Signed: 03/13/2024 10:26:59 AM

Document Has Been Signed on 03/13/2024 10:26 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:AMBITIONS - BRIGHTON AVENUEFACILITY NUMBER:
198602220
ADMINISTRATOR:KELLI PINKNEYFACILITY TYPE:
735
ADDRESS:21325 BRIGHTON AVETELEPHONE:
(310) 817-6100
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 3CENSUS: 2DATE:
03/13/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Kelli Pinkney TIME COMPLETED:
10:40 AM
NARRATIVE
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On 03/13/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent case management visit at the above facility. LPA met with Administrator Kelli Pinkney and explained the purpose of the visit was to deliver findings on the Department's investigation regarding a staff on client incident that occurred on 11/28/2023.

The investigation consisted of the following: On 11/30/2023, Licensing Program Analyst (LPA) Regina Cloyd conducted a case management visit. LPA reviewed clients and staff records and requested for the administrator to provide Staff#1 (S1) and Client #1 (C1) records electronically. LPA also requested for an electronic copy of the Personnel Report (LIC 500) and a copy of staff schedule for three months (September - November 2023). One staff and one client was interviewed. On 11/30/2023, Investigator Sonia Sandoval started her investigation which included request for records, record review, and interviews with witnesses, clients, and facility staff.

The investigation revealed the following, The interview of C1 revealed S1 headbutted, pushed C1 against the wall, picked up and slammed C1 on the floor. The interview of Staff #2 (S2) revealed during the unprovoked incident, S1 used profanity while addressing C1 and physically assaulted C1 (headbutting and slamming C1 on the floor). The interview of S1 revealed S1 failed to accept culpability for the incident, confirmed S1 failed to follow the facility protocol to refrain from engaging with agitated clients and confirmed C1 sustained the injury (fractured clavicle) during the incident. The review of the police report revealed C1’s and S2’s statements of the incident were consistent. Client C1 sustained an injury (fractured clavicle) when S1 physically assaulted C1 while in care. The preponderance of evidence has been met therefore the allegation that staff physically abused client while in care is substantiated.

Continue to LIC809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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 03/13/2024 10:26 AM - It Cannot Be Edited


Created By: Regina Cloyd On 03/13/2024 at 09:17 AM
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
MONTEREY PARK, CA 91754

FACILITY NAME: AMBITIONS - BRIGHTON AVENUE
FACILITY NUMBER: 198602220

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/14/2024
Section Cited
CCR
80072(a)(3)

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Personal Rights. Except for..., each client shall have personal rights which include, but are not limited to, the following: To be free from corporal or unusual punishment,... or other actions of a punitive nature...functioning. This requirement is not met as evidenced by:
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The Licensee separated Staff#1 (S1) on 12/09/23 from all of its facilities. The Administrator will develop and submit a plan of correction by the POC due date to regina.cloyd@dss.ca.gov
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Based on record review and interviews, the licensee did not comply with the section cited above. On 11/28/23, staff#1 physically abused client#1 while in care which posed an immediate safety rights risk to person 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:Ulysses Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024


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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMBITIONS - BRIGHTON AVENUE
FACILITY NUMBER: 198602220
VISIT DATE: 03/13/2024
NARRATIVE
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Deficiencies are being cited based on the findings of Investigator Sandoval in accordance with the California Code of Regulations, Title 22, see LIC809D. Civil penalties are being assessed, see LIC421IM. At this time, an enhanced civil penalty determination is pending reference to Health & Safety Code 1569.49(e)(1)(A) "Serious Bodily Injury" as defined in Section 243 of the Penal Code that states, "a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement."

An exit interview was conducted and plans of correction were developed and reviewed. A copy of this report and appeal rights were discussed and left with the Administrator Kelli Pinkney.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC809 (FAS) - (06/04)
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