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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547208780
Report Date: 01/07/2025
Date Signed: 01/08/2025 10:32:03 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/17/2024 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20241017090403
FACILITY NAME:AMBITIONS - MAE CARDENFACILITY NUMBER:
547208780
ADMINISTRATOR:ISAM, TAMMYFACILITY TYPE:
735
ADDRESS:2126 N MAE CARDEN CTTELEPHONE:
(559) 739-7975
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY:4CENSUS: 4DATE:
01/07/2025
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Jessica Mata, Administrator TIME COMPLETED:
02:48 PM
ALLEGATION(S):
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Staff due not ensure residents health care needs are being addressed
INVESTIGATION FINDINGS:
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On 01/07/25, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to deliver findings on the above allegation. LPA was greeted by staff, introduced self, stated the purpose of the visit, and was allowed entry into the facility. LPA met with Administrator to discuss the findings.

During the investigation, LPA conducted interviews and records review. On 10/04/24, day program staff called emergency services due to R1 having abnormal breathing. R1 was taken to the hospital via ambulance, diagnosed with an infection, treated and released home. On 10/15/24, R1 was observed to be wheezing and out of breath when they arrived at day program. S1 was advised by the day program that emergency services would be called for medical attention based on their observations of R1. R1 returned home and was reported to have no further wheezing. No medical attention was sought.

LPA observed Resident R1’s medical assessment (LIC 602) dated 08/16/24 to be incomplete and did not identify R1’s special problems and needs, prescribed medications being taken, or current medical status. Needs and Service appraisal/reappraisal was not observed in R1's file indicating the care and supervision needs of R1.

Based on the information received and per California Code of Regulations, Title 22, Division 6 Chapter 1, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. A deficiency is being cited on the attached LIC 9099D. An exit interview was conducted with Administrator, and a Plan of Correction was developed and reviewed by LPA with a due date of 01/08/25. A copy of this report and appeal rights were provided at the time of visit.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 24-AS-20241017090403
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: AMBITIONS - MAE CARDEN
FACILITY NUMBER: 547208780
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/08/2025
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.This requirement was not met as evidenced by LPAs records review. LPA did not observe a complete medical assessement, needs and service appraisal and/or reappraisal identifying R1's care and supervision needs.
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Administrator will submit a plan on how the regulation will be met by POC date.
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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.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/17/2024 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20241017090403

FACILITY NAME:AMBITIONS - MAE CARDENFACILITY NUMBER:
547208780
ADMINISTRATOR:ISAM, TAMMYFACILITY TYPE:
735
ADDRESS:2126 N MAE CARDEN CTTELEPHONE:
(559) 739-7975
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY:4CENSUS: 4DATE:
01/07/2025
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Jessica Mata, Administrator TIME COMPLETED:
02:48 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff handled resident in a rough manner during transfer
INVESTIGATION FINDINGS:
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13
On 01/07/25, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to deliver findings on the above allegation. LPA was greeted by staff, introduced self, stated the purpose of the visit, and was allowed entry into the facility. LPA met with Administrator to discuss the findings.

During the investigation, LPA conducted interviews and records reviews. Based on the information received, and although the allegation may have happened, there is not a preponderance of evidence to prove that the alleged violation occurred, therefore the allegation is Unsubstantiated.

Exit interview conducted and copy of report was provided at the time of visit.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3