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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608677
Report Date: 06/10/2023
Date Signed: 06/10/2023 03:29:39 PM


Document Has Been Signed on 06/10/2023 03:29 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
Lookup Error,
, CA



FACILITY NAME:AMBITIONS - VERDUGO 1FACILITY NUMBER:
197608677
ADMINISTRATOR:JESUS SANTANAFACILITY TYPE:
735
ADDRESS:2814 W VERDUGO AVETELEPHONE:
(818) 562-7246
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:4CENSUS: 3DATE:
06/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:Whitney Frame-RN ConsultantTIME COMPLETED:
03:30 PM
NARRATIVE
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On 6/10/2023 Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Whitney Frame/RN Consultant and the purpose of today’s visit was explained. The facility is licensed to operate for (4) non-ambulatory developmentally disabled or Mentally Ill adults ages 18 through 59. Currently, the home has (2) ambulatory and (1) non-ambulatory clients. The clients are from: Lanterman Regional Center. (2) clients have Restricted Health Care Conditions, and (1) is utilizing postural supports or protective devices

The facility is a single-story building in a residential area, with a kitchen, dining room, living room, 4 bedrooms, 2-bathroom, office space, backyard with ample shaded area and a garage.

LPA Iniguez and RN/Consultant toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathroom was found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105F°-120F° degrees (Kitchen 112.4F°, Bathroom #1 104.3°F., Bathroom #2 103.5F°).

Evaluation Report continues LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) -98-1755
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2023
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: AMBITIONS - VERDUGO 1
FACILITY NUMBER: 197608677
VISIT DATE: 06/10/2023
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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide/Smoke detectors combo were observed and operational. Fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked.

LPA conducted a records review of (3) client records (see D page for missing documents), (0) staff records (see D page for missing documents) and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administration Records (MAR) and did not observe any discrepancies at the time of visit.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

See D pages for Citations

Exit interview conducted with Whitney Frame/RN Consultant and a copy of the appeal rights were given at the time of the visit.


SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) -98-1755
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 06/10/2023 03:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA


FACILITY NAME: AMBITIONS - VERDUGO 1
FACILITY NUMBER: 197608677

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(f)
Administrator Qualifications and Duties
(f) When the administrator is absent from the facility there shall be coverage by a designated substitute, who meets the qualifications of Section 80065, who shall be capable, of, and responsible and accountable for, management and administration of the facility in compliance with applicable law and regulation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review the licensee did not comply with the section cited above in designating a substitute which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2023
Plan of Correction
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Licensee will ensure a designate person will be available when Administrator is absent from facility. Licensee wiil submit designated person to LPA by email.
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above in not having employees records at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2023
Plan of Correction
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Licensee will ensure employee records alre always present at facility. Lincensee will submitt a proof of correction via email to LPA of missing employee records noted on LIC 811
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: Eva M AlvarezTELEPHONE: (323) -98-1755
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 06/10/2023 03:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA


FACILITY NAME: AMBITIONS - VERDUGO 1
FACILITY NUMBER: 197608677

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above in not having personel records with TB test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2023
Plan of Correction
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Licensee will ensure all personell records are present at facility with TB test. Licensee will submitt TB test of employee records logged on LIC 811 and send a proof to LPA via email.
Type B
Section Cited
CCR
80070(b)
Client Records
(b) Each record must contain information including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in not having the SPV form in 2 clients records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2023
Plan of Correction
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Licensee will ensure all clients records are complete such as SPV for missing clients. Licensee will sub,itt proof of correction to LPA via emai.
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: Eva M AlvarezTELEPHONE: (323) -98-1755
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4