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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003781
Report Date: 01/27/2024
Date Signed: 01/27/2024 03:19:36 PM

Document Has Been Signed on 01/27/2024 03:19 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:AMBITIONS - SUNFIELD AVENUEFACILITY NUMBER:
306003781
ADMINISTRATOR:DAVENPORT, RENEEFACILITY TYPE:
735
ADDRESS:4734 SUNFIELD AVETELEPHONE:
(562) 982-4218
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 4CENSUS: 4DATE:
01/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Ashilee Jackson/Administrator DesigneeTIME COMPLETED:
03:19 PM
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On 1/27/2024 Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Ashilee Jackson/Administrator Designee and the purpose of today’s visit was explained. The facility is licensed to operate for (4) developmentally disabled or Mentally Ill adults ages 18-59. Restricted health care conditions. Currently, the home has (4) clients. The clients are from: Harbor Regional Center. (0) clients have Restricted Health Care Conditions, and (0) are utilizing postural supports or protective devices. The staff to client ration: 1-2.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) client's rooms, two (2) common bathrooms, a living area, dining area, kitchen, and outside patio area.

LPA Iniguez and administrator toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105F°-120F° degrees (Kitchen 107.4F°, Bathroom #1 106.5°F and Bathroom #2 105.5F°).

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 - SUNFIELD AVENUE
FACILITY NUMBER: 306003781
VISIT DATE: 01/27/2024
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LPA Iniguez observed the facility clean, sanitary, and appropriately furnished at the time of the visit. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. Carbon monoxide/Smoke detectors were observed and operational. Fire extinguishers were fully charged, toxins and knives were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Last facility disaster drill was:1/5/24. Administrator will email a copy of Surety Bond to LPA.

LPA conducted a records review of (3) client records, (3) staff records and (3) Client Medication Administration Records (MAR) and found no discrepancies. LPA reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit.


Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Civil Penalty Assessed.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Ashilee Jackson/Administrator Designee.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024
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Document Has Been Signed on 01/27/2024 03:19 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 01/27/2024 at 03:07 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AMBITIONS - SUNFIELD AVENUE
FACILITY NUMBER: 306003781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(4)
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: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 80019.1(r), unless, upon request for the transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in having a care staff not associated at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2024
Plan of Correction
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Licensee will ensure all staff are associated at the facility they work. As POC, licensee will associate staff to facility and will sent prof of association to LPA via email before 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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2024


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