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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003784
Report Date: 09/07/2023
Date Signed: 09/07/2023 12:06:30 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/28/2023 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230828140806
FACILITY NAME:AMBITIONS - KEYNOTE STREETFACILITY NUMBER:
306003784
ADMINISTRATOR:HARPS, ELTONFACILITY TYPE:
735
ADDRESS:6127 E KEYNOTE STTELEPHONE:
(562) 982-4221
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:4CENSUS: 4DATE:
09/07/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Keith PollardTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not prevent resident from punching another resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/07/23, at 09:30am, Licensing Program Analyst (LPA), Perry Scott conducted a 10-day complaint investigation at the facility listed above. LPA met with Keith Pollard, Administrator, and explained the purpose of today’s visit was to investigate the allegation listed above.

On 09/07/23, the investigation consisted of the following:

During today's visit LPA toured the facility. LPA requested and obtained copies of the following documents: Resident and Staff Roster, Physician’s Report, Individual Service Plan, ID/Emergency Information, Medical Appointment Record, SIR, and Appraisal/Needs and Service plans for C1 and C2. LPA interviewed staff (S1-S3) and clients (C1-C2).

The investigation revealed the following: Regarding allegation #1: Staff did not prevent resident from punching another resident.

Report continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
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 3
Control Number 11-AS-20230828140806
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMBITIONS - KEYNOTE STREET
FACILITY NUMBER: 306003784
VISIT DATE: 09/07/2023
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
26
27
28
29
30
31
32
On 09/07/23, at 10:00am-11:00am, LPA interviewed S1-S3. 3 of 3 staff admitted that C1 hit C2 while in the facility van because C2 stepped on C1’s foot while trying to exit the van. All staff stated that C1 felt remorseful for hitting C2, but the client was injured, nonetheless. The staff were not aware that C2 was injured until they noticed bruising on C2’s eye after they exited the van. LPA interviewed C1-C2, and C1 admitted that C1 had punched C2 in the eye causing an injury.

Based on interviews, observation, and records reviewed there is sufficient evidence to support the allegation: Staff did not prevent resident from punching another resident. The preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 1 are being cited on the attached LIC 9099D.

An exit interview was conducted with Keith Pollard, Administrator, and a hard copy of a LIC 9099 and LIC 9099D was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230828140806
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMBITIONS - KEYNOTE STREET
FACILITY NUMBER: 306003784
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2023
Section Cited
CCR
80072(a)(1)(3)
1
2
3
4
5
6
7
80072(a)(1)(3) Personal Rights. Except for children’s residential facilities, each client shall have specified personal rights. (1) To be accorded dignity in his/her personal relationships with staff and other persons. (3) To be free from corporal or unusual punishment, infliction of pain…The requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will provide in-service training to all staff for the following topics: Clients personal rights, de-escalating techniques, and techniques to redirect behaviors and submit a copy of training by POC due date 9/14/23, to LPA’s email address perry.scott@dss.ca.gov to avoid monetary penalties.
8
9
10
11
12
13
14
Based on evidence provided, interviews with administrator and staff, the facility failed to safeguard the client from being punched in the eye by another client causing the client to have a dislocated human lens, which may need surgery
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3