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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004223
Report Date: 08/29/2024
Date Signed: 08/29/2024 12:29:37 PM

Document Has Been Signed on 08/29/2024 12:29 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:AMBITIONS - ALBURY AVENUEFACILITY NUMBER:
306004223
ADMINISTRATOR/
DIRECTOR:		SMITH, STEPHNIEFACILITY TYPE:
735
ADDRESS:3836 ALBURY AVETELEPHONE:
(562) 982-4128
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 3CENSUS: 3DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:52 AM
MET WITH:Stephanie Smith,Client Care CoordinatorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 08/29/2024 at 8:50am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Stephanie Smith and the purpose of today’s visit was explained. The facility is licensed to operate for (3) ambulatory, (0) non-ambulatory, (0) bedridden for adults ages 18 through 59 (developmentally disabled. Currently, the home has (3) clients. The clients are (Harbor Regional Center) clients. None the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices.

The facility is a one (1) story home located in a residential neighborhood. The property consists of the following: three (3) client bedrooms, two (2) common bathrooms (with one (1) of the bathroom having a washer and dryer attached), staff office, living room, kitchen (water temperature tested at 111.0F), dining room, a garage (with a fridge for overflow of groceries), and an outdoor shaded area (with a table and chairs)0.

LPA conducted a records review of (3) client records, (4) staff records, (3) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administrations Records and did not observed any discrepancies at the time of visit.

At 9:00am LPA and Stephanie Smith toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed , plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105F -120F ( Bathroom #1 : 105.0 F) & Bathroom #2: 112.0 F).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 - ALBURY AVENUE
FACILITY NUMBER: 306004223
VISIT DATE: 08/29/2024
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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector is dual with smoke detectors was observed and operational. Fire extinguishers were fully charged (on January 17, 2024), toxins and knifes were locked and inaccessible to clients. Posted is emergency disaster plan. Last Emergency Drill was conducted on . Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

During todays visit LPA did not observe any deficiencies.

Exit interview conducted with (Stephanie Smith, Client Care Coordinator).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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