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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003784
Report Date: 03/13/2024
Date Signed: 04/18/2024 10:19:54 AM

Substantiated


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
03/06/2024 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20240306082422
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:
03/13/2024
UNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:ADMINSTRATOR KEITH POLLARDTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee does not ensure staff have appropriate training for colostomy care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This is an amendment of the complaint investigation report dated 03/13/2024, the purpose of this amendment is to provide additional information and delete a citation regarding Title 22 Regulation on 80092.2(a) Restricted Health Condition Care Plan.

On 03/13/2024 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Ambitions – Keynote Facility and was greeted by Administrator Keith Pollard (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained that the purpose of this visit is to initiate investigation on the above-mentioned allegation.

The investigation consisted of the following: During this investigation, LPA Calderon interviewed Administrator (A1), Staff (S1-S2), Client (C1) and Witness (W1). LPA Calderon obtained and reviewed C1’s client records, facility Personnel Report (LIC500) and Harbor Regional Center records.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
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 4
Control Number 11-AS-20240306082422
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 - KEYNOTE STREET
FACILITY NUMBER: 306003784
VISIT DATE: 03/13/2024
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
The investigation revealed the following: Regarding Allegation: “Licensee does not ensure staff have appropriate training for colostomy care”. It is being alleged that the licensee did not train staff to change C1’s colostomy bag. Interviews revealed that: A1 stated they received training from Prospect Medical Group and Ambitions facility nurse in February 2024 and 03/05/2024, but there is no written documentation proving said trainings were conducted. S1 confirmed changing C1’s colostomy bag “a few times”. S2 was not available for interview. Ambitions facility nurse confirmed that colostomy bag training was provided to facility in February 2024 and 03/05/2024 but does not have any documentation or signed the in-service log sheet or proof of the training. C1 states that C1 had colon surgery on 02/08/2024 and returned to the facility on 02/14/2024 and staff has changed C1 colostomy bag. Records reviewed indicate: Ambitions in-service training record dated 03/05/2024 was not signed by staff, therefore training cannot be verified.

Based on interviews and records reviews: the preponderance of evidence has been met, therefore the allegation “licensee does not ensure staff have appropriate training for colostomy care” is Substantiated. California Code of Regulations, Title 22, Division 6 are cited on the attached LIC 9099D.



An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to the Administrator Keith Pollard (A1).
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20240306082422
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 - KEYNOTE STREET
FACILITY NUMBER: 306003784
VISIT DATE: 03/13/2024
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
This is an amended 9099 page for 3/14/2024. The amended page is blank
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20240306082422
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 - KEYNOTE STREET
FACILITY NUMBER: 306003784
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2024
Section Cited
CCR
80092.4(a)(5)(B)
1
2
3
4
5
6
7
80092.4 Colostomy/Ileostomy (a)A licensee of an adult CCF may accept or rostomy bag and adhesive may be changed by facility staff who receive training from the licensed professional. This requirement has not been met as evidenced by:
1
2
3
4
5
6
7
Administrator will provide colostomy training to staff and email the in-service training logs with staff signatures by the POC date to LPA Calderon.
8
9
10
11
12
13
14
Based on interview, observation, and record review the licensee failed to ensure that the facility staff were trained to change colostomy bag for residents in care which posed a potential health risk to residents in care.
8
9
10
11
12
13
14
CCR
1
2
3
4
5
6
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
8
9
10
11
12
13
14
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: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4