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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208780
Report Date: 08/02/2022
Date Signed: 08/02/2022 12:46:18 PM

Document Has Been Signed on 08/02/2022 12:46 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 - 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:
08/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Tammy Isam TIME COMPLETED:
01:00 PM
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Licensing Program Analyst LPA Shawna Doucette conducted an Annual Inspection on this date. LPA was met by Staff Jaylyn Johnson and discussed the purpose of the visit. Client Care Coordinator Jessica Mata and Administrator Tammy Isam responded to the facility to assist with the inspection. LPA and began the tour at the front entrance/office of the facility with Client Care Coordinator Jessica Mata and Administrator Tammy Isam

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed behind a locked door in garage. LPA observed the following personal protective equipment in a storage cabinet in garage; gowns, face shield, gloves, and masks. Staff records were reviewed for infection control training. LPA observed all facility staff wearing masks. Resident’s files have updated emergency contact information.

LIC9102 was issued.

Exit interview was conducted and a copy of this report was provided
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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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