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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547208780
Report Date: 01/07/2025
Date Signed: 01/09/2025 09:11:58 AM

Document Has Been Signed on 01/09/2025 09:11 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 - MAE CARDENFACILITY NUMBER:
547208780
ADMINISTRATOR/
DIRECTOR:		MATA, JESSICAFACILITY TYPE:
735
ADDRESS:2126 N MAE CARDEN CTTELEPHONE:
(559) 739-7975
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY: 4CENSUS: 3DATE:
01/07/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:48 PM
MET WITH:Jessica Mata, Administrator TIME VISIT/
INSPECTION COMPLETED:
05:36 PM
NARRATIVE
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On 01/07/25, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to deliver findings on a complaint investigation. LPA was greeted by Staff S1, stated the purpose of the visit, and was allowed entry into the facility. LPA met with Administrator to discuss deficiencies observed during the course of LPA's investigation.

LPA Salazar reviewed Resident R1's facility file/records. R1's Needs and Service Plan (IPP) was not observed on file, R1's Medical Assessment (LIC 602) dated 11/14/24 was incomplete and did not have the required information. R1's Functional Capabilities assessment (LIC 9172) dated 11/14/24 had conflicting care and supervision needs. LPA observed diagnosis' for 4 out of 4 residents. Medical assessments (LIC602a) dated 12/26/24 state 4 out of 4 residents are ambulatory. Based on LPA's observation and records review, 4 out of 4 residents meet Title 22 definition of non-ambulatory. Facility license and fire clearance shows approval for 2 ambulatory and 2 non-ambulatory.

Based on the information received and per California Code of Regulations, Title 22, Division 6 Chapter 1, the following deficiencies are being cited on the attached LIC 809D. An immediate civil penalty in the amount of $500 is hereby assessed for fire clearance violation. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of clients in care.

Due to time and circumstances, LPA was not able to review report and deficiencies with Administrator on 01/08/25. LPA returned to the facility on 01/08/25 to review. On 01/08/25, an exit interview conducted with Administrator. A plan of correction was developed by Administrator and reviewed with LPA. POC date will be 24 hours from delivery of deficiency, which is 01/09/25. A copy of this report and appeal rights were discussed and provided to Administrator, whose signature on this form confirms receipt of this document.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/09/2025 09:11 AM - It Cannot Be Edited


Created By: Lisa Salazar On 01/07/2025 at 05:22 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: 01/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/08/2025
Section Cited
CCR
85068.3(a)

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85068.3 Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file. This requirement was not met as evidenced by LPAs records review, no needs and service appraisal and/or reappraisal was observed for R1 to indicate the specific are 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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This requirement was not met by LPA's observation of records reviewed. LPA did not observe a needs and services appraisal/reappraisal indicating the care and supervision needs.
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Type A
01/08/2025
Section Cited
CCR80020(b)(2)

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80020 Fire Clearance
(b) The applicant shall notify the licensing agency if the facility plans to admit any of the following categories of clients so that an appropriate fire clearance, approved by the city or county, fire department, the district providing fire protection services, or the State Fire Marshal, can be obtained prior to the acceptance of such clients: (2) Persons who are nonambulatory, as defined in Section 80001n.(1).
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Administrator will submit required forms for Fire clearance forms by POC date.
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This requirement was not met as evidenced by LPAs records review. 4 out of 4 residents in care are considered non-ambulatory. A civil penalty in the amount of $500 is hereby assessed for fire clearance. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of clients 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: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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/10/2025 11:17 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/09/2025 10:59 AM


Created By: Lisa Salazar On 01/08/2025 at 10:47 AM
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
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
01/09/2025
Section Cited
CCR
80069(c)

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80069 Client Medical Assessment
(c) The medical assessment shall include the following:(4) A determination of the client's ambulatory status, as defined by Section 80001(n)(2). 4 out of 4 residents medical assessments (LIC602a) dated 12/26/24 state 4 out of 4 residents are ambulatory. Based on LPA's observation and records review, 4 out of 4 residents meet Title 22 definition of non-ambulatory.
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Administrator will submit a plan on how the regulation will be met by POC date.
Type A
01/09/2025
Section Cited
CCR
85068.4(g)

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85068.4 Acceptance and Retention Limitations
(g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.
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Administrator will submit required forms and documentation for by POC date.
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This requirement was not met as evidenced by LPAs records review. 3 out of 4 residents in care are over the age of 60. 1 out of 4 is 59. No age exception request has been submitted to CCL as of this 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.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
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