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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208780
Report Date: 10/24/2024
Date Signed: 10/24/2024 12:58:38 PM

Document Has Been Signed on 10/24/2024 12:58 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/
DIRECTOR:		ISAM, TAMMYFACILITY TYPE:
735
ADDRESS:2126 N MAE CARDEN CTTELEPHONE:
(559) 739-7975
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 4CENSUS: 4DATE:
10/24/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:08 AM
MET WITH:Client Care CoordinatorTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 10/24/2024, Licensing Program Analysts (LPAs) Walton and Salazar arrived unannounced to conduct a case management inspection. LPAs introduced themselves, stated the purpose of the visit and requested to meet with the Administrator. LPAs met with Client Care Coordinator, Jaylyn Johnson. Administrator, Jessica Mata, arrived a short time later.

During the investigation for complaint number 24-AS-20241017090403, LPAs found that the 3 out of 3 dining chairs were in need of cleaning. LPAs also observed the adaptive chair, in the dining area, was in disrepair and observed to have holes in the side arms exposing the chair filing. The adaptive chair was also in need of cleaning.

During today's inspection, LPAs conducted a file review for residents in care. Upon review of records, LPAs found that the facility did not report an incident that occurred on 08/05/2024, when R1 was given "an extra LINZESS" when the medication had already been administered at 5:40AM. Facility staff contacted the primary care physician and informed to monitor. On 08/28/2024, the facility did not report when R1 was transported to the emergency room.

Further review of records revealed that the facility did not report that on 10/17/2024, R2 was taken to Urgent Care due to "wheezing" and facility staff was advised to take R2 to the emergency room for additional testing.

Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.

Exit interview and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Jessica Mata, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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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Document Has Been Signed on 10/24/2024 12:58 PM - It Cannot Be Edited


Created By: Alexandria Walton On 10/24/2024 at 12:17 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 - MAE CARDEN
FACILITY NUMBER: 547208780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2024
Section Cited
CCR
80075(b)

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80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications... this requirement was not met as evidenced by:
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for section 80075 are met to the Fresno CCL by the POC due date, to include the training documents and attendance for the training conducted by the third party training servcie
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Based on interviews and records reviews, the licensee did not comply with section 80075(b) when R1 was given an extra dosage of LINZESS, which is an immediate health and safety risk to persons in care.
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Type B
11/15/2024
Section Cited
CCR80061(b)

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80061 Reporting Requirements (b) Upon the occurrence... of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event... This requirement was not met as evidenced by:
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Licensee agrees to review section 80061 and conduct an in-service training. A copy of training topics and attendance will be submitted to the Fresno CCL office by the POC due date.
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Based on records review, the licensee did not comply with section 80061(b), when the facility failed to report incidents that occurred on 08/05/2024, 08/28/2024 and 10/17/2024 which is a potential health and safety risks to persons in care
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LPAs provided information regarding the techinal support program. Administrator accepted the offer to have the facility referred to the technical support program.

LPAs will make a referral for Technical support on behalf of the facility.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


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Document Has Been Signed on 10/24/2024 12:58 PM - It Cannot Be Edited


Created By: Alexandria Walton On 10/24/2024 at 12:28 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 - MAE CARDEN
FACILITY NUMBER: 547208780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors... this requirement was not met as evidenced by:
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Licensee agrees to have the chairs in the dining areas cleaned and/or repaired by the POC due date.
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Based on observation, the licensee did not comply with section 80087(a) when 4 out of 4 chairs in the dining areas were observed to be in disrepair and in need of cleaning, which is a potential health and safety risk to persons in care.
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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.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
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