<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208779
Report Date: 11/03/2023
Date Signed: 11/03/2023 06:43:08 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/03/2023 06:43 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:AMBITIONS - SUMTER COURTFACILITY NUMBER:
547208779
ADMINISTRATOR:ISAM, TAMMYFACILITY TYPE:
735
ADDRESS:1020 N SUMTER CTTELEPHONE:
5597397974
CITY:VISALIASTATE: CAZIP CODE:
93292
CAPACITY: 4CENSUS: 3DATE:
11/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Administrator (Admin) Tammy IsamTIME COMPLETED:
06:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
An unannounced Annual visit conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. McClurg. LPA was greeted at door by Direct Support Professional (DSP) Jaylyn Johnson. DSP contacted Administrator (Admin) Tammy Isam by phone. LPA stated purpose of visit & Admin stated that they would be there shortly LPA did state that cabinet in office containing medications was observed to be unlocked. Admin joined LPA later in visit.

LPA confirmed with DSP that they were the only staff working when LPA arrived. Upon entrance to facility LPA observed in office a with cabinet inside with doors open. Keys observed to be in lock of open cabinet. LPA observed that open cabinet contained resident medications as well as facility knives. Cabinet also contained a cleanser. Desk in office had locked box on it observed to be unlocked containing keys to medication storage in laundry room, facility van, & normally includes key to medication cabinet in office according to Admin. Screwdriver observed in top middle drawer of office desk in front of window.

Upon Admin arrival, LPA shared photos of open cabinet with hazardous contents, as well as lock box unlocked on desk in front of window, & screwdriver in drawer in desk under window. Admin could observe that cabinet in office was unlocked & that there was a screwdriver accessible in desk. Admin removed screwdriver, locked medication cabinet in office, & put keys in lockbox & locked the box @ time of visit.

This visit to be continued at a later date.

Deficiencies cited.
Exit interview conducted with Admin. Report provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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
Document Has Been Signed on 11/03/2023 06:43 PM - It Cannot Be Edited


Created By: Kelly J. McClurg On 11/03/2023 at 06:09 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: AMBITIONS - SUMTER COURT
FACILITY NUMBER: 547208779

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2023
Section Cited
CCR
80075(k)(1)

1
2
3
4
5
6
7
The following requirements shall apply to medications which are Centrally Stored Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
1
2
3
4
5
6
7
Administrator locked cabinet @ time of visit.

DEFICIENCY CLEARED @ TIME OF VISIT.
8
9
10
11
12
13
14
 LPA observed medication accessible in unlocked cabinet.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:See Moua
LICENSING EVALUATOR NAME:Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2