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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004226
Report Date: 08/25/2021
Date Signed: 08/25/2021 04:45:11 PM

Document Has Been Signed on 08/25/2021 04:45 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:AMBITIONS - FIDLER AVENUEFACILITY NUMBER:
306004226
ADMINISTRATOR:PENALOSA, NICHOLASFACILITY TYPE:
735
ADDRESS:13513 FIDLER AVETELEPHONE:
(310) 542-1390
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 3CENSUS: 3DATE:
08/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Celeste Orellana, Administrator
Keith Pollard, staff		TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Tao, conducted an unannounced annual inspection. The facility is licensed to serve three (3) ambulatory Developmentally Disabled Ambulatory clients, (age 18-59) with restricted health condition. Client census is three (3). LPA was allowed entry by Keith Pollard, staff. Administrator, Celeste Orellana, came and joined the visit 15 minutes later. Harbor Regional Center (HRC) in Torrance provides case management service to client residing in this home. The annual fee is paid. LPA discussed the purpose of today's visit.

During the visit, the following domain of the new inspection tool was used: infection control domain; a tour of the facility conducted; food supply was reviewed; and medications were reviewed.

Administrator, Celeste Orellana, assisted LPA with the visit. LPA toured the facility inside and outside. The home is located in a residential neighborhood within the city of Bellflower and is a one-story building which consists of three (3) client bedrooms, two (2) bathrooms, dining area, laundry area, living room, kitchen, attached garage, and patio with shaded area. Administrator certificate is current and expires on 8/10/2022.

Bedrooms were spacious which had the required furniture, easily accommodate the clients' furnishings, had appropriate linens and in good condition. Client bedrooms had beds, dressers, chairs and closet space available. Bathrooms are clean and operational.

Smoke detectors are combined with carbon monoxide devices. They are operable. Fire extinguishers’ last service was 1/20/2021 and they were fully charged. Fire drill was conducted on August 3, 2021. The first aid kit was fully stocked with a manual. Hot water temperature measured at 112.1 degrees Fahrenheit.

(-continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: AMBITIONS - FIDLER AVENUE
FACILITY NUMBER: 306004226
VISIT DATE: 08/25/2021
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Medications were centrally stored, locked in a cabinet located at the administrative area. Medications were properly logged and current. Hazardous items were locked and inaccessible to clients.

The required two (2) days perishable and seven (7) days non- perishable were observed. All burners and stove tops were in working condition.

Pesticides/poisons were not stored in food areas, kitchen, or where kitchen equipment/utensils were stored. Outside grounds were toured. Backyard was free of debris, exit ways and pathways were clear of hazards.

No deficiencies cited per California Code of Regulations, Title 22, Division 6.

An exit interview was conducted. This report is discussed and provided to facility Administrator, whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC809 (FAS) - (06/04)
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