<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003782
Report Date: 10/30/2023
Date Signed: 10/30/2023 04:33:15 PM

Document Has Been Signed on 10/30/2023 04:33 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, 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:
10/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Baltazar Cornejo, AdministratorTIME COMPLETED:
04:46 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/30/2023, at 2:45PM, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Annual required visit using the CARES tool. LPA was met by the Administrator, Baltazar Cornejo (S1), and the purpose of today’s visit was explained. The facility is licensed to operate for four (4) ambulatory developmentally disabled adults aged 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 a shaded outside patio area.
LPA toured the physical plant with S1. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in adequate condition, adequate 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. LPA observed cleaning chemicals, including a jug of bleach, below the bathroom #1 sink unlocked and potentially accessible to clients. The water temperature measured 110.6 degrees F. A comfortable temperature of 64 degrees F was maintained in the facility.
LPA observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene and sharps were stored and not accessible to clients. Screens throughout the facility were observed to be dirty, needing dusting and vacuuming of any remaining insects. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Two (2) Fire extinguishers were charged, as of 01/18/2023 and seven (7) smoke detectors, two of which show carbon monoxide sensors.
Two citations under title 22 regulations were cited, see LIC809-D. An exit interview was held with Baltazar Cornejo (S1) and a copy of this report and appeal rights were provided.
Due to time constraints, an annual continuation is required to complete an annual inspection and to conduct further record review using the CARE tool.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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 3
Document Has Been Signed on 10/30/2023 04:33 PM - It Cannot Be Edited


Created By: Mario Leon On 10/30/2023 at 04:17 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: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
1
2
3
4
Based on LPA [(observation, the licensee did not comply with the section cited above in having cleaning solutions, including bleach, being left unlocked below sink in bathroom #1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
1
2
3
4
LPA and Administrator have agreed to conduct an in-service staff training regariding keeping cleaning solutions inaccessible to clients. Administrator will send a copy of the length of time, section(s) covered and staff signatures of those involved to LPA via email, Mario.Leon@DSS.CA.GOV.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/30/2023 04:33 PM - It Cannot Be Edited


Created By: Mario Leon On 10/30/2023 at 04:24 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: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)

(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
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above throughout the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2023
Plan of Correction
1
2
3
4
LPA and Administrator Baltazar Cornejo have agreed that staff will clean the screens throughout the facility and will send video evidence of the cleanings to LPA via email, Mario.Leon@DSS.CA.GOV
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3