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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004223
Report Date: 10/07/2024
Date Signed: 12/05/2024 01:11:40 PM

Document Has Been Signed on 12/05/2024 01:11 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:
10/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:18 PM
MET WITH:Stepahnie SmithTIME VISIT/
INSPECTION COMPLETED:
03:02 PM
NARRATIVE
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On 10/07/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced Case Management visit at this facility. LPA was greeted by caregivers La Vida Childs and Lucia Bravo. Bravo contacted Program Administrator Stephanie Smith by telephone who join the visit. LPA explained to Smith the visit is associated with the health and safety inspection on 02/22/24 and 09/09/24 case management visits.

The investigation revealed that Client #1 (1) was physically assaulted/abused by staff #1 (S1) on 02/15/24. Staff #2 (S2) directly witnessed (S1) slap (C1) with an open hand. This conduct violated the client’s personal rights and extremely inappropriate behavior for a caregiver at CCL facility. It does not appear that (C1) suffered serious injury or exhibiting a mark afterward, but actual harm is not needed to validate the unwarranted action. Not only is there a direct eyewitness, but there are investigative reports from Harbor Regional Center and Long Beach Police Department reports that contained useful evidence to validate inappropriate behavior occurred.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 809-D).

An exit interview has been conducted and a copy of the Evaluation Report and Appeal Rights were provided to the Program Administrator (Stephanie Smith).

This report serves as an amendment to clarify line #7. It does not supersedes the investigation reflected on report created on 10/07/24.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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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Document Has Been Signed on 10/07/2024 02:49 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 10/07/2024 at 01:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AMBITIONS - ALBURY AVENUE
FACILITY NUMBER: 306004223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2024
Section Cited
CCR
80072(a)(3)

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80072(a)(3) Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include...(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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Licensee/Administrator shall ensure a training for all staff on Title 22, Section 80072 “Personal Rights” is conducted and send the sign in sheets and training materials to the CCLD by the Plan of Correction (POC) due date by 10/08/24.
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This requirement is not met as evidenced by: Staff failed to supervise Client #1 resulting in physical assault/abuse. The investigation did provide witness and internal and HRC investigation. This violatoni poses an immediate health and safety to clients in care.
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Corrected during visit on 10/07/24. In-Service Record Trainng Record conducted on 09/16/24 & 09/26/24
Facilty terminated employment of staff #1 on 03/05/24.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


LIC809 (FAS) - (06/04)
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