198200507-6-14-2023-11-AS-AINZ-CSSU8R-20230614152158

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198200507
Report Date: 06/14/2023
Date Signed: 06/14/2023 03:22:03 PM

Document Has Been Signed on 06/14/2023 03:22 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	ULTIMATE CARE III		FACILITY NUMBER:	198200507
ADMINISTRATOR:	DAVIS, CLINESE J.		FACILITY TYPE:	735
ADDRESS:	508 LOMA VISTA STREET		TELEPHONE:	(310) 640-7740
CITY:	EL SEGUNDO	STATE: CA	ZIP CODE:	90245
CAPACITY: 4		CENSUS:	DATE:	06/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:24 PM
MET WITH:	Ivana Reyes-Director of Client Services		TIME COMPLETED:	03:21 PM

NARRATIVE

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On 6/14/2023 Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Ivana Reyes/Director of Client Services and the purpose of today’s visit was explained. The facility is licensed to operate for (4) developmentally disabled or Mentally Ill adults ages 18 through 59. Currently, the home has (3) ambulatory. The clients are from: Westside Regional Center. (0) clients have Restricted Health Care Conditions, and (0) are utilizing postural supports or protective devices.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 2 bathrooms, family room, living room, kitchen, dining room/office, shaded area, indoor and outdoor activity area, laundry room in the detached garage.

LPA Iniguez and Director toured the inside and outside of the facility (see D page for citation). 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 118.5F°, Bathroom #1 114.3°F., Bathroom #2 116.4F°).

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ULTIMATE CARE III	FACILITY NUMBER: 198200507
	VISIT DATE: 06/14/2023

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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 extinguisher was 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, (3) staff records 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 page(s) for Citations.

Technical Advise given to Ivana Reyes regarding window frames

Exit interview conducted and a copy of the appeal rights were given to Ivana Reyes/Director of Client Services at the time of the visit.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/14/2023 03:22 PM - It Cannot Be Edited

Created By: Alfonso Iniguez On 06/14/2023 at 03:15 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ULTIMATE CARE III	FACILITY NUMBER: 198200507
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in keeping the facility in good repair which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/05/2023
	Plan of Correction
1 2 3 4	Licensee will ensure wall on on kitchen will be patched and painted. A proof of correction will be sent to LPA via email before POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Alvarez

LICENSING EVALUATOR NAME:

Alfonso Iniguez

LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC809 (FAS) - (06/04)

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