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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003782
Report Date: 11/01/2023
Date Signed: 11/01/2023 04:45:13 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/01/2023 04:45 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:
11/01/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Baltazar Cornejo, AdministratorTIME COMPLETED:
05:00 PM
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On 11/01/23 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent, unannounced, visit to the above mentioned facility to finish client and staff record reviews. LPA was met by LaCresha Grant, DSP2 (S2) and later by the Administrator, Baltazar Cornejo (S1). LPA was allowed entry to the facility 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. All four (4) clients are Harbor Regional Center consumers.
The visit consisted of record reviews of all four (4) clients and three (3) staff files. All client files were reviewed and it has been observed that all files contain a face sheet with proper ID/contact information, but only one (1) out of four (4) resident files contain Identification and Emergency Information (LIC601), all four (4) clients' folders contain current Physician Report (LIC602), one (1) out of (4) clients' files have a complete Admissions Agreement (SEE LIC604), two (2) out of four (4) clients' files contained personal rights information (LIC613), all four (4) clients' folders contain Individual Services Plan (ISP) which may suffice for the Appraisal/Needs Services Plan (LIC625). An advisory note of Technical Violation was provided, see LIC9102.
Three (3) staff files were reviewed and all staff files contain the required documentation.

An exit interview was conducted with Administrator, Baltazar Cornejo (S1) and a copy of this report and the advisory note was provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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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