306003782-3-14-2025-11-AS-EMAZ-DGPVX5-20250515164859

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003782
Report Date: 03/14/2025
Date Signed: 03/14/2025 02:13:06 PM

Unsubstantiated

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
03/10/2025 and conducted by Evaluator Deborah Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250310101234

FACILITY NAME:	AMBITIONS - 9TH STREET		FACILITY NUMBER:	306003782
ADMINISTRATOR:	TULANDA, TRESOR		FACILITY TYPE:	735
ADDRESS:	6711 E 9TH ST		TELEPHONE:	(562) 386-2616
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY:	4	CENSUS: 4	DATE:	03/14/2025
		UNANNOUNCED	TIME BEGAN:	08:42 AM
MET WITH:	Jassmond Johnson		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care
Staff not providing adequate supervision to resident in care.

INVESTIGATION FINDINGS:

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On March 14,2025, Licensing Program Analyst (LPA) Deborah Lee conducted a complaint visit regarding the above allegations. LPA Lee met with Jessmond Johnson Administrator and explained the reason for the visit.

The investigation consisted of the following:
On March 14, 2025, LPA Lee LPA reviewed and requested, the following: staff roster (dated 3/1/25 ), resident's roster (dated 3/14/25), body chedk document (dated 3/10/25), Client Progress notes (dated 3/9/25, 3/10/25), Physician's Report for R1 (dated 4/20/24), Medication list/physician orders (dated 3/1/25), client appointment communication (dated 3/11/25); Incident Reporting Policy, SIRs (dated 3/11/25; 10/23/24), suspension letter (dated 3/12/25), R1 appraisal/Needs and Services Plan (dated 4/22/24), Individual Program Pan for R1 (dated 8/29/24). LPA conducted the following intervews: (2) Residents (R1-R2), Licensee (A1), and (4) staff (S1-S4)

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20250310101234

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: 03/14/2025

NARRATIVE

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Investigation revealed the following:

Allegation: Resident sustained unexplained injuries while in care

The detail of the complaint alleges that on 3/9/25 at 7:55am, R1 had a busted bottom lip and night staff claimed resident fell but was unable to provide details on how the resident fell. On 3/14/25, LPA interviewed Administrator (A1) who stated that she was aware of the incident and took R1 to Urgent Care for treatment once she became aware of the incident and witnessed his injury. A1 provided LPA copy of aftercare visit paperwork (dated 3/11/25). A1 reported incident to placement agency and CCL. Copy provided to LPA. A1 stated that R1 did not require any stitches at the time of his urgent care visit but was given a supply of antibiotics. LPA interview 4 staff and of those interviewed, (4) of (4) indicated that they are aware of reporting requirements and know who to report incidents to and the time frame that they are to report. LPA interviewed the 2 verbal residents (R2 and R3). Of those interviewed (2) of (2) residents stated that staff tends to their needs. (2) out of (2) residents told LPA that they feel safe at the facility and are treated well. On 3/14/25, LPA review the following documents: body check document (dated 3/10/25), Client Progress notes (dated 3/9/25, 3/10/25), client appointment communication (dated 3/11/25); Incident Reporting Policy, SIRs (dated 3/11/25; 10/23/24) and client progress notes (dated 3/9/25, 3/10/25). Documents reviewed indicate that facility took appropriate steps following the reported incident.

Based on the information gathered, there is insufficient evidence to support the stated allegation.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20250310101234

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: 03/14/2025

NARRATIVE

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Allegation: Staff not providing adequate supervision to resident in care.

The detail of the complaint alleges that in November and December 2024, R1 had scrapes on his face and the side of his legs and put his finger in hot oatmeal resulting in him being taken to the hospital for his injuries. LPA interviewed A1 who stated that R1 has eczema, and he constantly scratches which results in marks on his body. A1 provided LPA with a copy of physician's orders (dated 3/1/25) which includes 2 types of eczema creams. Lastly, A1 provided LPA with a copy of SIR addressing incident of R1's injury from putting his finger in hot oatmeal. On 3/14/25, LPA interviewed 4 staff members. Of those interviewed 3 of 4 stated that they feel there is adequate staff to meet resident’s needs. 1 of 4 staff stated that the facility could use additional staff, because sometimes facility is short staffed due to “call outs.” LPA interviewed 2 residents and (2) out of (2) stated that staff are available to help them when they need it.

Based on the information gathered, there is insufficient evidence to support the stated allegation.

Although the allegations above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation are UNSUBSTANTIATED.

No deficiencies were cited for the above allegations. Exit interview was conducted. A copy of this report was provided to Jassmond Johnson Administrator.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC9099 (FAS) - (06/04)

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