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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200507
Report Date: 08/22/2021
Date Signed: 08/22/2021 10:55:57 AM

Document Has Been Signed on 08/22/2021 10:55 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:
08/22/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Felicia Ncham, Care giverTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Health and Safety case management visit to the above facility. LPA was met by Felicia Ncham, Care giver and the purpose of today's visit was explained,

LPA Soto toured the entire facility. The mandated posting for CCLD and DPH are posted through out the facility with the exception of laundry room, posting are still needed there. Portable carts are still needed, they will be delivered today in the afternoon.

An exit interview was conducted with Felicia Ncham , Care giver and a hard copy of report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2021
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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