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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208779
Report Date: 08/03/2022
Date Signed: 08/03/2022 11:02:18 AM

Document Has Been Signed on 08/03/2022 11:02 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:AMBITIONS - SUMTER COURTFACILITY NUMBER:
547208779
ADMINISTRATOR:ISAM, TAMMYFACILITY TYPE:
735
ADDRESS:1020 N SUMTER CTTELEPHONE:
(559) 739-7974
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 4CENSUS: 1DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:17 AM
MET WITH:Administrator Tammy Isam TIME COMPLETED:
10:15 AM
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On 08/3/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with Bianka Romero, caregiver. Administrator Tammy Isam was called and arrived later during tour. LPA conducted a facility tour with caregiver. There are currently one client present during tour.

Upon entry facility staff was observed with facial mask. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to clients and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings in facility.

LPA checked client’s locked medications and observed a 30-day PPE supplies. Food supply was checked and appeared to be an adequate supply. LPA observed fire extinguisher served date: 11/17/21.

Client’s room toured and observed to be adequately furnished and lit. LPA observed one bedroom that are single occupant and three vacant bedrooms. All bathrooms observed trash bin with lid. LPA observed hand washing posting by all sinks. Cleaning supplies were stored and locked in cabinet in the garage, under kitchen sink and laundry room.

The exterior tour was conducted. Outside free of obstruction. Staff records were reviewed for good health and infection control training. Client record reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 8/9/22. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 402, Lic 610D, and Lic 9020. LPA received copy of Lic 500, control of property, and current Administrator certificate. A copy of this report was provided to Administrator. Signed copy on file.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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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