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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200507
Report Date: 08/20/2021
Date Signed: 08/22/2021 10:58:23 AM

Document Has Been Signed on 08/22/2021 10:58 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ULTIMATE CARE IIIFACILITY NUMBER:
198200507
ADMINISTRATOR:DAVIS, CLINESE J.FACILITY TYPE:
735
ADDRESS:508 LOMA VISTA STREETTELEPHONE:
(310) 640-7740
CITY:EL SEGUNDOSTATE: CAZIP CODE:
90245
CAPACITY: 4CENSUS: 4DATE:
08/20/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Ivana ReyesTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ana Soto initiated a case management - Health and Safety check for the above facility along with Kathleen from DPH. Today’s case management was conducted with Ivana Reyes, and Ladonna Good (Administrator for Westside Regional Center.)

LPA, Kathleen, Ivana and LaDonna toured the entire facility. LPA & Kathleen inspected the facility for sign to be posted on front door and side door for Health Order and Pins from CCLD. The sign-in area had a sign in sheets for all visitors and staff. The bedroom and bathroom signs were posted on the doors to identify Covid - 19 positive clients. Isolation carts to store Full PPE's (Gowns, Gloves, N95 masks, face shield and hand sanitizer,) are still needed. The carts will be taken to all red zone rooms. Restrooms have trash cans with tight fitting lids. Laundry room has a trash can with a tight fitting lid and it has a sign to remind staff to wash clothes from clean to dirty. Social Distancing precautions have been taken with the furniture in all common areas and patio area. An EPA approved disinfectants are available in all common areas. A sign was posted on the wall next to the facility phone. The facility will put the minutes needed to wait on all cleaning solutions before wiping surfaces.

An exit interview conducted with Ivana Reyes, and a hard copy was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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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