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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003964
Report Date: 04/05/2022
Date Signed: 04/06/2022 10:42:30 AM

Document Has Been Signed on 04/06/2022 10:42 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:AMBITIONS - VAN RUITEN STREETFACILITY NUMBER:
306003964
ADMINISTRATOR:PENALOSA, NICKFACILITY TYPE:
735
ADDRESS:9284 VAN RUITEN STTELEPHONE:
(310) 817-6100
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 4CENSUS: 4DATE:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Monique Capers TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required visit. LPA met with DSP Monique Capers and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, observed food supply and review clients files. Facility has submitted a mitigation plan and was approved 07/29/2021.

The facility is a single story house and located in a neighborhood area. The facility included Living room, dining area, kitchen, TV room, four clients bedrooms, two bathrooms, laundry area, detached garage and a supervisor office next to the garage. All 4 clients bedrooms were toured. Each bedroom has a working smoke detector, bed, linen, dresser, light, and sufficient closet space. All 2 bathrooms were toured and they are clean and sanitary. The hot water in two bathrooms was measured between 108.7 and 109.3 degrees F which is within the Title 22 regulation. The refrigerator in the kitchen, kitchen cabinet and garage has sufficient two days perishable and seven days non perishable food supply. All the appliance are clean and working properly. The common areas such as living room, TV room and dining area are clean and have the required furniture. The front and back yard are maintained well and the back yard has a shaded area with tables and chairs for client to utilize.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, disinfecting products are available in each room and facility is disinfected everyday, restrooms have sufficient soap, paper towels, and signs.

No deficiencies were found during this visit. Exit interview was conducted with DSP Monique Capers and a copy of this report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2022
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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