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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003782
Report Date: 02/17/2024
Date Signed: 02/17/2024 01:06:18 PM

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
08/11/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220811154107
FACILITY NAME:AMBITIONS - 9TH STREETFACILITY NUMBER:
306003782
ADMINISTRATOR:TULANDA, TRESORFACILITY TYPE:
735
ADDRESS:6711 E 9TH STTELEPHONE:
(562) 386-2616
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY:4CENSUS: 4DATE:
02/17/2024
UNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Renee Davenport TIME COMPLETED:
01:07 PM
ALLEGATION(S):
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Resident sustained unexplained injuries while in care.
INVESTIGATION FINDINGS:
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On 02/17/24, Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Direct Support Provider (S2: Lacresha Grant) who contacted Program Administrator (A5:Renee Davenport). LPA conducted a risk assessment prior to entering the facility. S2 informed LPA that the facility has no COVID cases nor do any of the clients or direct support personnel have symptoms. The purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegation.

The investigation consisted of the following:
A 24-hour visit was conducted by Licensing Program Analyst (LPA) Martessa Brown on 08/12/22 for health & safety purposes and to ensure the wellbeing of clients in care. The investigation consisted of the following: a tour of the physical plant and all clients were in the facility.

(Evaluation Report continues LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2024
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-20220811154107
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 - 9TH STREET
FACILITY NUMBER: 306003782
VISIT DATE: 02/17/2024
NARRATIVE
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 During today’s visit, LPA reviewed the following documents. Resident Roster (dated 03/10/22), Staff Roster & DSP Work Schedules (dated 11/12/21), Client #1 Face Sheet (dated 01/18/18), ID/Emergency Info (dated 03/10/22), Individual Personal Plans (period 04/20/22), Medication Administration Records (dated August 2022), Admissions Agreements (dated 01/18/22), Behavioral Support Plans, Physicians Reports (dated 03/10/22), Incident Report (dated 08/09/22), Body Check – Clinical Chart (dated 08/08/22 and 08/09/22), Redirection Tracking Sheet (dated 09/05/22 thru 09/11/22); Administrator and Staff training records (05/04/21 thru 04/04/22). Harbor Regional Center (HRC) Incident Report (dated 08/10/22). Long Beach Fire Dept (LBFD) Incident Report, Ambulance Transport Services report (dated 08/09/22), and Patient Release form (dated 08/09/22). Long Beach Police Dept (LBPD) Incident Report (dated 08/09/22).

The complaint was referred to the California Department of Social Services Investigations Branch and was assigned to investigator (Heidy Bendana) which included a review of medical records (dated 08/09/22); interviews of medical services personnel (Witness #3 - #6); local law enforcement (W#1, W#2, W#10); Harbor Regional Center staff (W#7, W#9); Facility Staff #A2, #S1, #S2, #S3, #S4, #S6; and Clients #1, #2.

INVESTIGATION REVEALED THE FOLLOWING:

Regarding Allegation #1: This investigation revealed that Client #1 sustained multiple injuries based on medical records from St. Mary Medical Center (dated 08/09/22), Long Beach Fire Dept Incident Report (dated 08/09/22), and Long Beach Police Dept Report DR# 22-39040 (dated 08/09/22). Reports notated that Client #1’s injuries were consistent with physical abuse and the injury patterns matched the object (potato smasher) patterns that was collected (in the facility’s kitchen) as evidence. These marks caused Client #1’s skin to turn a reddish color and were observed on the client’s back, below the right armpit, left bicep area, left buttocks, inner thighs, left shoulder blade - adjacent to the right armpit, and lower left leg - near the thigh area (photographs). Client #1 was discharged from the hospital on 08/10/22 with a diagnosis of hematoma due to physical abuse; and it was documented that the injury patterns matched the object (potato smasher) patterns used in the physical abuse.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20220811154107
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 - 9TH STREET
FACILITY NUMBER: 306003782
VISIT DATE: 02/17/2024
NARRATIVE
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Based on evidence gathered, interviews conducted, records reviewed, and photographs, the preponderance of evidence standard has been met; therefore, the allegation of PHYSICAL ABUSE: Resident sustained unexplained injuries while in care is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099D). Civil penalty assessed.

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to the Program Administrator Renee Davenport.

*IMMEDIATE CIVIL PENALTY*

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20220811154107
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 - 9TH STREET
FACILITY NUMBER: 306003782
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/18/2024
Section Cited
CCR
80072(A)(3)
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Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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Licensee/Administrator shall ensure a training for all staff on Title 22, Section 80072 “Personal Rights” is conducted and send a the sign in sheets and training materials to the CCLD by the Plan of Correction (POC) due date 02/18/24 - FAX to 424-544-1016 attn: E. Ceniceros.
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This requirement is not met as evidenced by: Staff failed to supervise Client #1 resulting in the client sustaining multiple injuries. A1 retained (former) staff #1 who did not have a Criminal Record Clearance authorized to work. The investigation did provide sufficient evidence that the marks on Client #1 are consistent with inflicted bodily injuries. Civil penalties assessed in the amount of Five-hundred Dollars ($500). This violation posed an immediate health and safety to clients in care.
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IMMEDIATE CIVIL PENALTY
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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: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4