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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003782
Report Date: 08/13/2022
Date Signed: 08/13/2022 05:32:07 PM

Document Has Been Signed on 08/13/2022 05:32 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
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:
08/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Lacresha Grant TIME COMPLETED:
05:15 PM
NARRATIVE
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On 08/13/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with the caregiver Lacresha Grant. LPA explained the purpose of today’s visit. The facility is licensed to operate for four (4) ambulatory developmentally disable adults ages 18 through 59 years. The clients are Harbor Regional Center consumers.

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 toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in adequate condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were stocked at the visit. Bathrooms were operational condition. The water temperature measured 105.3 degrees F. A comfortable temperature of 72 degrees was maintained in the facility.

LPA observed the facility to be furnished at the time of visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguisher was charged, and smoke detectors and carbon monoxide were operable. The facility maintains a Certificate of Liability Insurance in current status.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMBITIONS - 9TH STREET
FACILITY NUMBER: 306003782
VISIT DATE: 08/13/2022
NARRATIVE
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DEFICIENCIES:
During the inspection, LPA identified at 2:48 pm bathroom #1 without a window screen. At 2:50 pm, LPA identified a missing bedroom door for client #4 (C4). At 2:51 pm, LPA observed a bathtub in bathroom #2 in need of repair. The seal/grout around the perimeter of the tub has porous. The tub base is stained with mildew. At 2:55 pm, LPA identified cleaning solutions and other toxic items under the kitchen sink with a broken cabinet lock. At 3:00 pm, LPA observed (3) gallons of paint in the garage not kept in locked storage.

Due to time constraints and the administrator not being available during this visit, an annual continuation is required to complete a health and safety inspection and conduct Infection Control questionnaires.

Deficiencies are issued and an exit interview is conducted with Lacresha Grant. A copy of this report is provided along with the appeal rights.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/13/2022 05:32 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/13/2022 at 04:19 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
MONTEREY PARK, CA 91754

FACILITY NAME: AMBITIONS - 9TH STREET
FACILITY NUMBER: 306003782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(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.

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 identified cleaning solutions, paint and other hazardous materials not kept in a locked storage. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2022
Plan of Correction
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The licensee will adhere to regulations 80087 and remove and store all hazardous items in a locked storage compartment. The licensee will send proof of correction by POC 08/14/22.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/13/2022 05:32 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/13/2022 at 04:19 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
MONTEREY PARK, CA 91754

FACILITY NAME: AMBITIONS - 9TH STREET
FACILITY NUMBER: 306003782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) (interview), the licensee did not comply with the section cited above. LPA identified for client #4 (C4) did not have a bedroom door for privacy and kitchen cabinet under the sink had a broken lock. This violation which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2022
Plan of Correction
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The licensee will adhere to regulations 80087 and repair the broken lock cabinet under the kitchen sink and replace a missing bedroom door for (C4). The licensee will send proof of correction by POC 08/27/22.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on obsevation, the licensee did not comply with the section cited above. LPA identified a bathroom window missing a screen in bathroom #1. This violation which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2022
Plan of Correction
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The licensee will adhere to regulations 80088 will replace missing window screen. The licensee will send proof of correction by POC 08/27/22
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:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/13/2022 05:32 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/13/2022 at 04:20 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
MONTEREY PARK, CA 91754

FACILITY NAME: AMBITIONS - 9TH STREET
FACILITY NUMBER: 306003782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

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 identified in bathroom #2 a tub with stains, mildew and broken seal/grout. This violation which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2022
Plan of Correction
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The licensee will adhere to regulations 80088 and repair the the seal/grout and remove staines and mildrew from bathtub. The licensee will send proof of correction by POC 09/13/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2022


LIC809 (FAS) - (06/04)
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