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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 09:10:21 AM

Document Has Been Signed on 01/09/2025 09:10 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 - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:37 PM
MET WITH:Jessica Mata, Administrator TIME VISIT/
INSPECTION COMPLETED:
07:53 PM
NARRATIVE
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On 01/07/25, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a case management visit based on a self reported incident reports. LPA was greeted by Staff S1, stated the purpose of the visit, and was allowed entry into the facility.

On 10/17/24 @ 7:41AM, it was reported that R1 was wheezing and had shortness of breath. Staff S1 and Staff 2 notified Staff S3, who was stated to arrive to the facility shortly. S3 instructed S2 to take R1 to Urgent Care where R1 was diagnosed with Pleural effusion. S2 was advised by Urgent care to take R1 to Emergency Room (ER). R1 was seen @ Kaweah Medical Health Center ER where they did blood work and was discharged home with antibiotics @ 2PM. LPA requested discharge papers and documentation of R1's follow up appointments.

On 11/09/24 @ 0813AM Staff S4 reported to S3 that an incident occurred @ 0600AM when R1 was walking to their room with staff assistance, lost their balance and fell to their knees then over on their side. S4 did a body check and stated , other than redness, R1 seemed fine. @ 0813 AM, Staff S5 notified S3 that R1 was limping. S3 instructed S5 to take R1 to Urgent Care. It was reported R2 was OK, that they would be sore for a couple of days. On 11/12/24, records show R1 was taken back to urgent care for x-rays and was diagnosed with a bimalleoar ankle fracture and then referred to Kaweah Delta Healthcare Hospital ER. LPA obtained hospital discharge paper and requested additional documentation evidencing follow up care.

On 11/29/24 @ 9:30PM, Staff S4 stated while assisting Resident R2 out of the living room chair when R2 slid out of the chair and scooted on their bottom to the bathroom where staff assisted in changing R2. R2 then was assisted to their bedroom by S4 when R2 decided to scoot to their bed and scratched/bruised themselves on a bed rail. S4 informed S3. On 12/01/24, R2's bruise looked worse and was taken to Urgent care where they were diagnosed with a contusion on the left lower back. LPA asked for documentation evidencing medical treatment was sought.

(Continued on LIC 809-C)
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)
Page: 1 of 3
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
VISIT DATE: 01/07/2025
NARRATIVE
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(Continued from LIC 809)

On 12/19/24 @ it was reported @8:30PM, R1 had a seizure and 911 was called. R1 was taken to Kaweah Delta Healthcare hospital where blood tests were taken R1 was diagnosed with a Urinary Tract Infection (UTI) and release home, no medications noted. LPA req

On 01/01/25 @ 1:10PM, S5 reported to S3 that 911 was called for an incident with R2. S5 stated R2 dropped to the floor while being assisted from the bathroom to the living room. Staff S6 assisted S5 in transferring R2 from the floor to a wheelchair. S5 was transferring R2 from the wheelchair to the living room chair, when R2 put alot of weight on their leg/ankle. S5 heard a pop and saw blood. Staff S7 911 was called and R2 was transported to Kaweah Delta Healthcare ER, where R2 were diagnosed with a fractured Tibia and Fibula. R2 has surgery on 01/02/25 and is currently in the hospital.

LPA has requested the following information by 01/10/25:
1.) Personnel records - LIC 501/contact information and current staff training records for Staff S1, S2, S4, S5, S6 and S7.
2.) LIC 602a / Needs and Service appraisal or IPP for R1 and R2
3.) Documentation evidencing R1 returned for follow up medical appointments for the 10/17/24 and 12/19/24 4.) Staff Schedule for November 2024, December 2024 and January 2025.

LPA observed 3 out of 4 residents in care at the time of inspection. LPA toured the facility inside and out and observed a 7 day supply of non perishable food and a 2 day supply of perishable food. LPA observed the house to be free from debris, clutter and any fire clearance obstruction. Facility inside temperature measured at 70 degrees F, facility water temperature measured at 116.9.

Based on the information received and per California Code of Regulations, Title 22, Division 6 Chapter 1, Deficiencies are being cited on the attached LIC 809D. An immediate civil penalty in the amount of $500 is hereby assessed for a violation that resulted in the injury or illness of 2 our of 4 individuals in care. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of clients in care. Issuance of deficiencies and additional civil penalties, if any, are pending and currently under review.
Due to time and circumstances, LPA was not able to review report and deficienices with Administrator on 01/97/25. 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: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/09/2025 09:10 AM - It Cannot Be Edited


Created By: Lisa Salazar On 01/08/2025 at 10:54 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
, 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
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 of incident report. 2 out of 4 residents in care were delayed medical treatment for illness and injuries. A civil penalty in the amount of $500 is hereby assessed. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of clients in care. Issuance of deficiencies and additional civil penalties, if any, are pending and currently under review.
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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
80075(a)

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80075 Health Related Services
(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
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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 as evidenced by LPAs review of records, R1's had a fall on 11/09/25. Medical treatment was delayed for 3 days. R1 was taken for x-ray on 11/12/24, which resulted in a diagnosis of a Bimalleoar ankle fracture.
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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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