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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003784
Report Date: 03/22/2023
Date Signed: 03/22/2023 04:17:39 PM

Document Has Been Signed on 03/22/2023 04:17 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 - 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:
03/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:47 PM
MET WITH:Keith Pollard, AdministratorTIME COMPLETED:
04:33 PM
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On 3/22/23 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Case Management inspection. LPA met with Keith Pollard, Administrator (A1), to discuss the purpose of todays visit which involves gathering information surrounding the altercation between Client #1 and Client #2, which occurred on March 07, 2023.

During the visit LPA interviewed A1, Client #1 and Client #2.

Investigation:
LPA interviewed A1, Client #1 and Client #2 making sure that the clients have been informed on keeping their hands to themselves and staying away from each others beverages or food to avoid future altercations.

A copy of this report was left with Administrator, Keith Pollard.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
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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